Articulating suturing device

ABSTRACT

An apparatus for closing an opening in a body tissue. The apparatus includes a shaft, a plurality of arms, and an expander. The arms each extend between a proximal end and a distal end. The distal end of each arm is hingedly attached to or integrally formed with the shaft. The arms are laterally spaced apart from each other. The arms are movable between a retracted configuration, in which the arms are each aligned along the shaft, and a deployed configuration, in which the proximal end of each arm pivots respectively about the distal end of the arm so as to extend laterally away from the shaft. The expander is positioned within the shaft, and movement of the expander causes the arms to move between the retracted and deployed configurations. Methods of using the apparatus are also included.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.13/725,589, filed Dec. 21, 2012, the entire contents of which areincorporated by reference herein.

BACKGROUND OF THE INVENTION

1. The Field of the Invention

The present disclosure provides apparatuses and methods that aresuitable for closure of vascular punctures or other openings in bodilytissues. More particularly, the present disclosure relates toapparatuses and techniques for tightening sutures about an opening toclose the opening, which is usually accessed through a tissue tract.

2. The Relevant Technology

A number of diagnostic and interventional vascular procedures are nowperformed translumenally. A catheter is introduced to the vascularsystem at a convenient access location and guided through the vascularsystem to a target location using established techniques. Suchprocedures require vascular access, which is usually established duringthe well-known Seldinger technique, as described, for example, inWilliam Grossman's “Cardiac Catheterization and Angioplasty,” 3.sup.rdEd., Lea and Febiger, Philadelphia, 1986, incorporated herein byreference. Vascular access is generally provided through an introducersheath, which is positioned to extend from outside the patient body intothe vascular lumen.

When vascular access is no longer required, the introducer sheath isremoved and bleeding at the puncture site stopped. One common approachfor providing hemostasis (the cessation of bleeding) is to applyexternal force near and upstream from the puncture site, typically bymanual or “digital” compression. This approach suffers from a number ofdisadvantages. It is time consuming, frequently requiring a half hour ormore of compression before hemostasis is assured. Additionally, suchcompression techniques rely on clot formation, which can be delayeduntil anticoagulants used in vascular therapy procedures (such as forheart attacks, stent deployment, non-optical PTCA results, and the like)wear off. This can take up to two to four hours, thereby increasing thetime required before completion of the compression technique. Thecompression procedure is further uncomfortable for the patient andfrequently requires analgesics to be tolerable. Moreover, theapplication of excessive pressure can at times totally occlude theunderlying blood vessel, resulting in ischemia and/or thrombosis.Following manual compression, the patient typically remains recumbentfrom four to as much as twelve hours or more under close observation soas to assure continued hemostasis. During this time renewed bleeding mayoccur, resulting in blood loss through the tract, hematoma and/orpseudoaneurysm formation, as well as arteriovenous fistula formation.These complications may require blood transfusion and/or surgicalintervention.

The incidence of complications from compression-induced hemostasisincreases when the size of the introducer sheath grows larger, and/orwhen the patient is anticoagulated. It is clear that the compressiontechnique for arterial closure can be risky, and is expensive andonerous to the patient. Although the risk of complications can bereduced by using highly trained individuals, dedicating such personnelto this task is both expensive and inefficient. Nonetheless, as thenumber and efficacy of translumenally performed diagnostic andinterventional vascular procedures increases, the number of patientsrequiring effective hemostasis for a vascular puncture continues toincrease.

To overcome the problems associated with manual compression, the use ofbioabsorbable fasteners or sealing bodies to stop bleeding haspreviously been proposed. Generally, these approaches rely on theplacement of a thrombogenic and bioabsorbable material, such ascollagen, at the superficial arterial wall over the puncture site. Whilepotentially effective, this approach suffers from a number of problems.It can be difficult to properly locate the interface of the overlyingtissue and the adventitial surface of the blood vessel. Locating thefastener too far from that interface can result in failure to providehemostasis, and subsequent hematoma and/or pseudo-aneurysm formation.Conversely, if the sealing body intrudes into the arterial lumen,intravascular clots and/or collagen pieces with thrombus attached canform and embolize downstream, causing vascular occlusion. Also, thrombusformation on the surface of a sealing body protruding into the lumen cancause a stenosis, which can obstruct normal blood flow. Other possiblecomplications include infection, as well as adverse reaction to thecollagen or other implant.

A more effective approach for vascular closure has been proposed in U.S.Pat. Nos. 5,417,699, 5,613,974; and PCT published Patent Application No.PCT/US96/10271 filed on Jun. 104, 1996, the full disclosures of whichare incorporated herein by reference. A suture-applying device isintroduced through the tissue tract with a distal end of the deviceextending through the vascular puncture. One or more needles in thedevice are then used to draw suture through the blood vessel wall onopposite sides of the puncture, and the suture is secured directly overthe adventitial surface of the blood vessel wall to provide highlyreliable closure.

While a significant improvement over the use of manual pressure, clamps,and collagen plugs, certain design criteria have been found to beimportant to successful suturing to achieve vascular closure. Forexample, it is highly beneficial to properly direct the needles throughthe blood vessel wall at a significant distance from the puncture sothat the suture is well anchored in the tissue and can provide tightclosure. It is also highly beneficial to insure that the needledeployment takes place when the device is properly positioned relativeto the vessel wall. The ease of deployment and efficacy of the procedurecan further be enhanced by reducing the cross-section of that portion ofthe device, which is inserted into the tissue tract and/or the vesselitself, which may also allow closure of the vessel in a relatively shortamount of time without imposing excessive injury to the tissue tract orvessel.

For the above reasons, it would be desirable to provide improveddevices, systems, and methods for suturing vascular punctures. The newdevice should have the capability of delivering one or more pre-tiedknot to an incision site. It would be particularly beneficial if theseimproved devices provided some or all of the benefits while overcomingone or more of the disadvantages discussed above.

BRIEF SUMMARY OF THE INVENTION

The present disclosure provides apparatuses and methods that aresuitable for closure of vascular punctures or other openings in bodilytissues. More particularly, the present disclosure relates toapparatuses and techniques for tightening sutures about a tissue openingto close the opening, which is usually accessed through a tissue tract.

In one aspect of the invention, there is provided an apparatus forclosing an opening in a body tissue. The apparatus has a shaft, firstand second arms, and an expander. The shaft extends along an axisbetween a proximal end and a spaced apart distal end. The shaft has asize and configuration suitable for insertion through an opening in bodytissue. The first and second arms each extend between a proximal end anda distal end. The distal end of each arm is hingedly attached to orintegrally formed with the shaft. The first and second arms are movablebetween a retracted configuration, in which the first and second armsare each aligned along the shaft, and a deployed configuration, in whichthe proximal end of each of the first and second arms pivot respectivelyabout the distal end of the respective arm so as to extend laterallyaway from the shaft. The expander is positioned within the shaft, andmovement of the expander causes the first and second arms to movebetween the retracted and deployed configurations.

The proximal ends of the arms can extend laterally away from the shaftin opposite directions in the deployed configuration. The expander canbe positioned within a lumen of the shaft, can be substantially conical,and can be threaded. Movement of the expander in the distal directioncan cause the proximal ends of the arms to laterally move to thedeployed configuration. Alternatively, movement of the expander in theproximal direction can cause the proximal ends of the arms to laterallymove to the deployed configuration.

The apparatus can also include a flexible filament having first andsecond ends that are removably coupled with the first and second arms,respectively, and first and second penetrators positioned proximal ofthe first and second arms. The first and second penetrators can beadvanceable distally from the shaft to the first and second arms in thedeployed configuration.

The apparatus can also include third and fourth arms, each extendingbetween a proximal end and a distal end. The distal ends of the thirdand fourth arms can be hingedly attached to or integrally formed withthe shaft and the fourth arm can be laterally spaced apart from thethird arm. The third and fourth arms can also be movable between aretracted configuration, in which the third and fourth arms are eachaligned along the shaft, and a deployed configuration, in which theproximal end of each of the third and fourth arms pivot respectivelyabout the distal end of the respective arm so as to extend laterallyaway from the shaft. The third and fourth arms can be caused to movebetween the retracted and deployed configurations by movement of theexpander. The proximal ends of the third and fourth arms can extendlaterally away from the shaft in opposite directions in the deployedconfiguration that are different than the lateral directions of theproximal ends of the first and second arms.

The apparatus can also include a second flexible filament having firstand second ends that are removably coupled with the third and fourtharms, respectively, and third and fourth penetrators positioned proximalof the third and fourth arms. The third and fourth penetrators can beadvanceable distally from the shaft to the third and fourth arms in thedeployed configuration.

In another aspect of the invention there is provided a method forclosing an opening extending through a tissue wall. The method includesthe steps of inserting a distal end of a tissue locator distally throughthe opening, the tissue locator comprising a first arm and a second armeach extending between a proximal end and a distal end, the first andsecond arms each being aligned along a shaft of the tissue locator in aretracted configuration, the tissue locator being inserted far enoughthrough the opening that the first and second arms are positioned distalof the tissue wall, first and second ends of a flexible filamentrespectively being removably coupled with the first and second arms;pivoting the proximal end of each of the first and second arms of thetissue locator about the distal end of the respective arm to move theproximal ends of the first and second arms from the retractedconfiguration to a deployed configuration in which the proximal ends ofthe first and second arms extend laterally away from the shaft;advancing a first penetrator and a second penetrator distally throughthe vessel wall such that the first and second penetrators respectivelycouple with the first and second ends of the flexible filament; andwithdrawing the first and second penetrators proximally through thevessel wall, thereby causing the first and second ends of the filamentto uncouple from the first and second arms, the first end of theflexible filament remaining coupled with the first penetrator such thatthe first end of the filament withdraws proximally through the vesselwall with the first penetrator.

The distal ends of the arms can remain aligned along a shaft of thetissue locator in the deployed configuration. The distal ends of thearms can be integrally formed with the shaft of the tissue locator.Alternatively, the distal ends of the arms can be hingedly attached tothe shaft of the tissue locator. The distal ends of the arms can flexoutward when the proximal ends of the arms move to the deployedconfiguration. The proximal ends of the first and second arms can extendin opposite lateral directions when the arms are in the deployedconfiguration. The second end of the flexible filament can remaincoupled with the second penetrator such that the second end of thefilament withdraws proximally through the vessel wall with the secondpenetrator.

The step of pivoting the proximal ends of the arms can be accomplishedby moving an arm expander axially along the shaft so as to cause alaterally outward force to occur on the arms. The step of moving the armexpander axially can be accomplished by moving the arm expanderproximally to cause the laterally outward force to occur on the arms.Alternatively, the step of moving the arm expander axially can beaccomplished by moving the arm expander distally to cause the laterallyoutward force to occur on the arms.

The tissue locator can further include third and fourth arms eachextending between a proximal end and a distal end, and first and secondends of a second flexible filament can be removably coupled with thethird and fourth arms. The third and fourth arms can also each bealigned along the shaft of the tissue locator in the retractedconfiguration and positioned distal of the tissue wall when the tissuelocator is inserted through the opening.

The method can further include: pivoting the proximal end of each of thethird and fourth arms of the tissue locator about the distal end of therespective arm to move the proximal ends of the third and fourth armsfrom the retracted configuration to a deployed configuration in whichthe proximal ends of the third and fourth arms extend laterally awayfrom the shaft; advancing a third penetrator and a fourth penetratordistally through the vessel wall such that the third and fourthpenetrators respectively couple with the first and second ends of thesecond flexible filament; and withdrawing the third and fourthpenetrators proximally through the vessel wall, thereby causing thefirst and second ends of the second filament to uncouple from the thirdand fourth arms, the first end of the second flexible filament remainingcoupled with the third penetrator such that the first end of the secondfilament withdraws proximally through the vessel wall with the thirdpenetrator.

The second end of the second flexible filament can remain coupled withthe fourth penetrator such that the second end of the second filamentwithdraws proximally through the vessel wall with the fourth penetrator.

The step of pivoting the proximal end of each of the third and fourtharms of the tissue locator can be performed concurrently with pivotingthe proximal end of each of the first and second arms; and the step ofwithdrawing the third and fourth penetrators proximally through thevessel wall can be performed concurrently with drawing the first andsecond penetrators proximally through the vessel wall. The proximal endsof the third and fourth arms can extend in opposite lateral directionsfrom each other and in lateral directions different than the lateraldirections of the proximal ends of the first and second arms when thethird and fourth arms are in the deployed configuration. The step ofmoving the arm expander axially along the shaft can also cause alaterally outward force to occur on the third and fourth arms to pivotthe third and fourth arms laterally outward.

In another aspect of the invention, there is provided an apparatus forclosing an opening in a body tissue. The apparatus has a shaft, three ormore arms, and an expander. The shaft extends along an axis and has asize and configuration suitable for insertion through an opening in bodytissue. The three arms are attached to or integrally formed with theshaft and are laterally spaced apart from each other. The arms aremovable between a retracted configuration, in which the arms are eachaligned along the shaft, and a deployed configuration, in which the armseach extend laterally away from the shaft in different directions. Theexpander causes the arms to move between the retracted and deployedconfigurations.

The apparatus can include a plurality of flexible filaments each havingfirst and second ends that are removably coupled with separate ones ofthe three or more arms, and a penetrator associated with each arm. Eachpenetrator can be positioned proximal of the respective arm, and can beadvanceable distally from the shaft to the respective arm in thedeployed configuration.

The apparatus can include a suture net having multiple ends that areeach removably coupled with separate ones of the three or more arms, anda penetrator associated with each arm. Each penetrator can be positionedproximal of the respective arm, and can be advanceable distally from theshaft to the respective arm in the deployed configuration.

The three or more arms can be four to six arms. The expander can bepositioned within a lumen of the shaft.

In another aspect of the invention there is provided a method forclosing an opening extending through a tissue wall. The method includesthe steps of inserting a distal end of a tissue locator distally throughthe opening, the tissue locator comprising three or more arms, eachbeing aligned along a shaft of the tissue locator in a retractedconfiguration, the tissue locator being inserted far enough through theopening that the three or more arms are positioned distal of the tissuewall, an end of a filament or a filament net link being removablycoupled with each of the arms; pivoting the proximal ends of each of thefirst and second moving the three or more arms of the tissue locatorfrom the retracted configuration to a deployed configuration in whichthe three or more arms extend laterally away from the shaft in differentdirections; for each arm, advancing a penetrator distally through thevessel wall to couple with the end of the filament net or flexiblefilament associated with the arm; and withdrawing the penetratorsproximally through the vessel wall, thereby causing the ends of thefilament net or the filaments to uncouple from the three or more arms,at least one end of the filament net or of each flexible filamentremaining coupled with at least one of the penetrators such that thecorresponding end of the filament net or each filament withdrawsproximally through the vessel wall with the corresponding penetrator.

All of the ends of the filament net or flexible filaments can remaincoupled with the corresponding penetrators such that all of the ends ofthe filament net or flexible filaments withdraw proximally through thevessel wall with the three or more penetrators.

In another aspect of the invention, there is provided an apparatus forclosing an opening in a body tissue. The apparatus has a shaft, aplurality of arms, a plurality of flexible filaments, and a penetratorassociated with each arm. The shaft extends along an axis between aproximal end and a spaced apart distal end and has a size andconfiguration suitable for insertion through an opening in body tissue.The plurality of arms are attached to or integrally formed with theshaft. The plurality of flexible filaments each has a first end and asecond end; the first and second ends of the flexible filaments areremovably coupled with separate ones of the plurality of arms. Eachpenetrator is positioned proximal of the respective arm and isadvanceable distally through a vessel wall to the respective arm tocouple with the end of the filament associated with the arm. Thepenetrators are configured to withdraw at least a portion of each of thefilaments through the vessel wall.

The arms can be laterally spaced apart from each other. The arms can bemovable between a retracted configuration, in which the arms are eachaligned along the shaft; and a deployed configuration in which the armsextend laterally away from the shaft. The apparatus can also include anexpander which causes the arms to move between the retracted anddeployed configurations. The expander can be positioned within a lumenof the shaft.

In another aspect of the invention there is provided a method forclosing an opening extending through a tissue wall. The method includesthe steps of inserting a distal end of a tissue locator distally throughthe opening, the tissue locator comprising a plurality of arms, eachbeing aligned along a shaft of the tissue locator in a retractedconfiguration, the tissue locator being inserted far enough through theopening that the plurality of arms are positioned distal of the tissuewall, a plurality of flexible filaments being removably coupled with theplurality of arms; moving the plurality of arms from the retractedconfiguration to a deployed configuration in which the plurality of armsextend laterally away from the shaft; for each arm, advancing apenetrator distally through the vessel wall to couple with an end of oneof the flexible filaments; and withdrawing the penetrators proximallythrough the vessel wall, thereby causing the ends of the filaments touncouple from the plurality of arms, at least one end of each of theflexible filaments remaining coupled with the respective penetrator suchthat the coupled ends of the filaments withdraw proximally through thevessel wall with the respective penetrators.

All of the ends of the flexible filaments can remain coupled with thecorresponding penetrators such that all of the ends of the filamentswithdraw proximally through the vessel wall with the penetrators.

In another aspect of the invention, there is provided an apparatus forclosing an opening in a body tissue. The apparatus has a shaft, aplurality of arms, a flexible net, and a penetrator associated with eacharm. The shaft extends along an axis between a proximal end and a spacedapart distal end and has a size and configuration suitable for insertionthrough an opening in body tissue. The plurality of arms are attached toor integrally formed with the shaft. The filament net has plurality ofends; each end of the filament net is removably coupled with a separateone of the arms. Each penetrator is positioned proximal of therespective arm and is advanceable distally through a vessel wall to therespective arm to couple with the end of the filament net associatedwith the arm. The penetrators are configured to withdraw the ends of thefilament net through the vessel wall.

The arms can be laterally spaced apart from each other. The arms can bemovable between a retracted configuration, in which the arms are eachaligned along the shaft; and a deployed configuration in which the armsextend laterally away from the shaft. The apparatus can also include anexpander which causes the arms to move between the retracted anddeployed configurations. The expander can be positioned within a lumenof the shaft. The apparatus can also include a flexible filamentremovably coupled with separate ones of the arms.

In another aspect of the invention there is provided a method forclosing an opening extending through a tissue wall. The method includesthe steps of inserting a distal end of a tissue locator distally throughthe opening, the tissue locator comprising a plurality of arms, eachbeing aligned along a shaft of the tissue locator in a retractedconfiguration, the tissue locator being inserted far enough through theopening that the plurality of arms are positioned distal of the tissuewall, separate ends of a filament net being removably coupled with eachof the arms; moving the plurality of arms of the tissue locator from theretracted configuration to a deployed configuration in which theplurality of arms extend laterally away from the shaft; for each arm,advancing a penetrator distally through the vessel wall to couple withthe end of the filament net associated with the arm; and withdrawing thepenetrators proximally through the vessel wall, thereby causing the endsof the filament net to uncouple from the plurality of arms and withdrawproximally through the vessel wall with the penetrators.

The step of moving the plurality of arms of the tissue locator can beaccomplished by pivoting a proximal end of each arm about a distal endof the respective arm.

In another aspect of the invention, there is provided an apparatus forclosing an opening in a body tissue. The apparatus has a shaft, aplurality of arms, a filament net or plurality of flexible filaments, apenetrator associated with each arm, and a plurality of penetratoractuators. The shaft extends along an axis between a proximal end and aspaced apart distal end and has a size and configuration suitable forinsertion through an opening in body tissue. The plurality of arms areattached to or integrally formed with the shaft and are movable betweena retracted configuration, in which the arms are each aligned along theshaft of the tissue locator, and a deployed configuration in which thearms extend laterally away from the shaft. The filament net or pluralityof flexible filaments have multiple ends and each of the ends areremovably coupled with a separate one of the plurality of arms. Eachpenetrator is positioned proximal of the respective arm and isadvanceable distally through a vessel wall to the respective arm tocouple with the end of the filament or filament net associated with thearm. The penetrators are configured to withdraw the ends of the filamentor filament net through the vessel wall. The actuators are eachassociated with a different penetrator so that the penetrators aremovable independent of each other by the penetrator actuators.

In another aspect of the invention there is provided a method forclosing an opening extending through a tissue wall. The method includesthe steps of inserting a distal end of a tissue locator distally throughthe opening, the tissue locator comprising a plurality of arms, eachbeing aligned along a shaft of the tissue locator in a retractedconfiguration, the tissue locator being inserted far enough through theopening that the plurality of arms are positioned distal of the tissuewall, at least one flexible filament or web being removably coupled withthe plurality of arms; moving the plurality of arms from the retractedconfiguration to a deployed configuration in which the plurality of armsextend laterally away from the shaft; for each arm, advancing apenetrator distally through the vessel wall to couple with the at leastone flexible filament or web associated with the arm, the penetratorsbeing movable independent of each other; and withdrawing the penetratorsproximally through the vessel wall, thereby causing the at least oneflexible filament or web to uncouple from the plurality of arms andwithdraw proximally through the vessel wall with the penetrators.

Each penetrator can be advanced at different times from each other. Eachpenetrator can have a separate penetrator actuator associated therewithand can be advanced and withdrawn by manually manipulating theassociated penetrator actuator.

In another aspect of the invention there is provided a method forclosing an opening extending through a tissue wall. The method includesthe steps of inserting a distal end of a tissue locator distally throughthe opening, the tissue locator comprising a plurality of arms, eachbeing aligned along a shaft of the tissue locator in a retractedconfiguration, the tissue locator being inserted far enough through theopening that the plurality of arms are positioned distal of the tissuewall; advancing a plurality of penetrators distally to attempt topenetrate through the vessel wall, each penetrator being associated witha different one of the arms, one or more penetrators not penetratingthrough the vessel wall; removably coupling separate ends of a filamentnet with the plurality of arms, the one or more arms associated with thenonpenetrating penetrators not being coupled with the filament net;moving the plurality of arms from the retracted configuration to adeployed configuration in which the plurality of arms extend laterallyaway from the shaft; for each arm associated with penetratingpenetrators, advancing a penetrator distally to penetrate through thevessel wall, the penetrators penetrating through the wall to couple withthe end of the filament net associated with the corresponding arm; andwithdrawing the penetrators proximally, thereby causing the ends of thefilament net to uncouple from the plurality of arms and withdrawproximally through the vessel wall with the penetrators.

These and other advantages and features of the present disclosure willbecome more fully apparent from the following description and appendedclaims, or may be learned by the practice of the disclosure as set forthhereinafter.

BRIEF DESCRIPTION OF THE DRAWINGS

Various embodiments of the present invention will now be discussed withreference to the appended drawings. It is appreciated that thesedrawings depict only typical embodiments of the invention and aretherefore not to be considered limiting of its scope. In the drawings,like numerals designate like elements. Furthermore, multiple instancesof an element may each include separate letters appended to the elementnumber. For example two instances of a particular element “20” may belabeled as “20 a” and “20 b”. In that case, the element label may beused without an appended letter (e.g., “20”) to generally refer to everyinstance of the element; while the element label will include anappended letter (e.g., “20 a”) to refer to a specific instance of theelement.

FIGS. 1A and 1B are perspective views of a tissue closure device,respectively showing a pair of arms in retracted and deployed positionsaccording to one embodiment of the present invention;

FIGS. 2A-C are perspective views of a tissue closure device according toanother embodiment, showing actuation of a pair of arms and advancementof needles from a shaft to the arms;

FIGS. 3A-3D are cross-sectional side and top views of one embodiment ofa tissue locator that can be used in the tissue closure devices shown inFIGS. 1 and 2 showing the arms in the retracted position (FIGS. 3A and3B) and in the deployed position (FIGS. 3C and 3D). FIG. 3B is takenalong the section line 3B-3B of FIG. 3A and FIG. 3D is taken along thesection line 3D-3D of FIG. 3C;

FIG. 3E depicts the movement of the arms of the tissue locator shown inFIGS. 3A-3D, between the retracted and deployed positions;

FIG. 3F is a close-up cross-sectional view of a penetrator receptaclewith a cuff disposed therein;

FIG. 4 is a perspective view of a cuff that can be used with embodimentsof the present invention;

FIGS. 5A-5D are cross-sectional side and top views of another embodimentof a tissue locator that can be used in the tissue closure devices shownin FIGS. 1 and 2 showing the arms in the retracted position (FIGS. 5Aand 5B) and in the deployed position (FIGS. 5C and 5D). FIG. 5B is takenalong the section line 5B-5B of FIG. 5A and FIG. 5D is taken along thesection line 5D-5D of FIG. 5C;

FIGS. 6A-6D are cross-sectional side and top views of another embodimentof a tissue locator that can be used in the tissue closure devices shownin FIGS. 1 and 2 showing the arms in the retracted position (FIGS. 6Aand 6B) and in the deployed position (FIGS. 6C and 6D). FIG. 6B is takenalong the section line 6B-6B of FIG. 6A and FIG. 6D is taken along thesection line 6D-6D of FIG. 6C;

FIGS. 7A-7C are cross-sectional side views showing the needles beforeand after engagement with the suture cuffs in the retracted and deployedarms;

FIG. 8 is a perspective view illustrating a suture attachment cuff andan associated barbed needle;

FIG. 9 illustrates a suture cuff and attached suture positioned within apenetrator receptacle;

FIGS. 10A-10C illustrate alternative structures and techniques foravoiding entanglement of the needle with the suture;

FIGS. 11A-G illustrate a method of using a tissue closure device havingthe tissue locator shown in FIGS. 5A-5D;

FIGS. 12A-D illustrate an alternative method of using a tissue closuredevice having the tissue locator shown in FIGS. 5A-5D;

FIGS. 13A and 13B illustrate various embodiments of pre-tied knots thatcan be used with embodiments of the present invention;

FIGS. 14A and 14B are schematic views of a suture bight having apre-tied knot in accordance with one embodiment of the presentinvention;

FIGS. 15A-D illustrate one embodiment of a method of attaching a sutureto a cuff and releasing the cuff from the arm using a penetrator andthen disengaging the penetrator from the cuff;

FIGS. 16A and 16B illustrate an alternative embodiment for releasing thecuff from the arm;

FIGS. 17A and 17B are perspective views of an alternative embodiment ofa penetrator tip;

FIGS. 18A through 18C are schematic views of an alternate embodiment ofa penetrator and how it can be used to engage with a link;

FIGS. 19A through 19G are schematic views of an alternate embodiment ofa penetrator that includes a clamp and ring assembly;

FIG. 20 shows a schematic view of one embodiment of a cuff and linkassembly;

FIGS. 21A-21D are cross-sectional side and top views of anotherembodiment of a tissue locator that can be used in the tissue closuredevices shown in FIGS. 1 and 2 showing the arms in the retractedposition (FIGS. 21A and 21B) and in the deployed position (FIGS. 21C and21D). FIG. 21B is taken along the section line 21B-21B of FIG. 21A andFIG. 21D is taken along the section line 21D-21D of FIG. 21C;

FIGS. 22A-22D are cross-sectional side and top views of anotherembodiment of a tissue locator that can be used in the tissue closuredevices shown in FIGS. 1 and 2 showing the arms in the retractedposition (FIGS. 22A and 22B) and in the deployed position (FIGS. 22C and22D). FIG. 22B is taken along the section line 22B-22B of FIG. 22A andFIG. 22D is taken along the section line 22D-22D of FIG. 22C;

FIGS. 23A through 23D are perspective views of a penetrator actuationhandle in various modes of operation;

FIGS. 24A and 24B are schematic views, respectively, of a linkcombination and a corresponding tissue closure formed thereby, accordingto one embodiment;

FIGS. 25A and 25B are schematic views, respectively, of a linkcombination and a corresponding tissue closure formed thereby, accordingto another embodiment;

FIGS. 26A and 26B are schematic views, respectively, of a linkcombination and a corresponding tissue closure formed thereby, accordingto another embodiment;

FIGS. 27A and 27B are schematic views, respectively, of a linkcombination and a corresponding tissue closure formed thereby, accordingto another embodiment;

FIGS. 28A and 28B are schematic views of a suture net and correspondingtissue closure formed thereby, according to one embodiment;

FIGS. 29A and 29B are schematic views of a suture net and correspondingtissue closure formed thereby, according to another embodiment;

FIGS. 30A and 30B are schematic views of a suture net and correspondingtissue closure formed thereby, according to another embodiments;

FIGS. 31A and 31B are schematic views of a suture link used inconjunction with a suture net and a corresponding tissue closure formedthereby, according to another embodiment;

FIGS. 32A through 32C illustrate a method of using a suture net to closea tissue opening when one portion of the suture net is unusable,according to one embodiment.

DETAILED DESCRIPTION

As used in the specification and appended claims, directional terms,such as “top,” “bottom,” “up,” “down,” “upper,” “lower,” “proximal,”“distal,” and the like are used herein solely to indicate relativedirections and are not otherwise intended to limit the scope of theinvention or claims.

The present disclosure provides methods and apparatuses to locate adistal wall of a tissue through an opening in the tissue. Someembodiments of the devices and methods described herein are suitable forclosure of vascular punctures or other openings in the tissue. Forexample, in some embodiments, one or more sutures can be positionedthrough the tissue adjacent an opening so the opening can be closedusing the sutures.

Generally, the apparatuses and methods described herein for tissuelocation can be used with any type of body tissue. Embodiments used toclose openings in tissue can be used with any type of body tissue thathas sufficient strength to be held together by sutures. By way ofexample only, embodiments of the present invention can be used to closeopenings in tissues that have a wall or membrane function, e.g,pulmonary, intestinal, vascular, urethral, gastric, renal or other wallstructures, or in membranes, e.g., amniotic or pericardial membranes.Openings in other types of tissues can also be closed using embodimentsof the present invention. Although many types of body tissue can beclosed by the methods and apparatuses disclosed herein, the descriptionincluded herein refers to “vessels” for convenience.

Furthermore, the apparatuses and methods described herein can be usedwith large and small hole punctures or other openings in the bodytissue. By way of example, embodiments of the present invention can beused to close holes from 5 French to 30 French or larger. It may also bepossible to close holes of other sizes using embodiments of the presentinvention.

Turning now to the drawings, FIGS. 1A and 1B illustrate a tissue closuredevice 100 having a housing 102 and a shaft 104 extending therefrom.Housing 102 supports a penetrator actuation handle 106 at a proximal end108 thereof, and an arm actuation handle 110. Shaft 104 extends distallyfrom housing 102 from a proximal end 112 to a spaced apart distal end114. A flexible, atraumatic monorail guide body 116 can extend distallyfrom distal end 114 of shaft 104.

A tissue locator 118 is positioned at distal end 114 of shaft 104.Tissue locater 118 includes a pair of arms 120 a and 120 b positionednear distal end 114 of shaft 104. Arms 120 can move between a lowprofile, retracted position, in which each arm is substantially alignedalong an axis 122 of shaft 104, to a deployed, expanded position, inwhich the arms extend laterally away from shaft 104. The retractedposition of arms 120 is shown in FIG. 1A and the deployed position isshown in FIG. 1B. The movement of arms 120 between the retracted anddeployed positions and back again can be effected by actuation of armactuation handle 110. Arm actuation handle 110 can comprise a handlethat pivots about a hinged point, as in the depicted embodiment, or cancomprise a mechanism that uses a rotary action, a linear action, a camaction, or any other type of action that can move arms 120 between theretracted and deployed positions. The movement of penetrators to andfrom the deployed arms 120 can be effected by actuation of penetratoractuation handle 106. Penetrator actuation handle 106 can comprise ahandle that linearly moves, as in the depicted embodiment, or cancomprise a mechanism that uses a picoting action, a rotary action, a camaction, or any other type of action that can move the penetrators to andfrom the deployed arms 120.

FIGS. 2A-2C illustrate another embodiment of a tissue closure device 130having a modified proximal housing 132. Similar to tissue closure device100, tissue closure device 130 includes a pair of arms 120 that can bemoved between the retracted and deployed positions using an armactuation handle 134. FIG. 2C also shows how penetrators 136 can beadvanced distally from shaft 104 to arms 120 by depressing a penetratoractuation handle 138.

Arms 120 and the actuation thereof are illustrated more clearly in thecross sectional views of FIGS. 3A-3E. FIGS. 3A and 3B depict arms 120 aand 120 b in the retracted position, and FIGS. 3C and 3D depict arms 120a and 120 b in the deployed position. FIG. 3E shows the movement of arms120 a and 120 b between the two positions; the retracted position isshown in solid lines while the deployed position is shown in dashedlines. As can be seen in FIGS. 3A-3E, arms 120 a and 120 b areessentially identical except that they are positioned on oppositelateral sides of tissue locator 118 so as to be diametrically opposed toeach other.

Each arm 120 of tissue locator 118 extends from a proximal end 150 to aspaced apart distal end 152. To allow arms 120 to move between theretracted and deployed positions, distal end 152 of each arm 120 isattached to or formed with shaft 104 so as to be pivotable with respectto shaft 104. That is, each arm 120 is configured to pivot about itsdistal end 152 to cause proximal end 150 to move radially inward andoutward with respect to axis 122, as shown in FIG. 3E. This can beaccomplished by making at least the distal end 152 of each arm 120 outof a resiliently bendable material. Alternatively, a hinge (not shown)can be attached between distal end 152 of arm and shaft 104 to aid inthe pivoting action, if desired.

With reference to FIGS. 3A and 3B, each arm 120 has an outer surface 154and an opposing inner surface 156 extending from distal end 152 to anend face 158 positioned at proximal end 150. Outer surface 154 facesradially away from axis 122 and can be curved to substantially match thecurvature of shaft 104, if desired. Inner surface 156 faces radiallytowards axis 122. If desired, inner and outer surfaces 156 and 154 canbe formed so that the thinnest portion (laterally) of each arm 120occurs at the distal end 152 thereof to aid in the pivoting of the armthereat.

In the retracted position illustrated in FIGS. 3A and 3B, arms 120 a and120 b extend substantially along axis 122 of shaft 104. If outersurfaces 154 of arms 120 are curved to substantially match the curvatureof shaft 104, tissue locator 118 can essentially form a bridge betweenthe portions of shaft 104 positioned proximally and distally of arms120. Tissue locater 118 can have a similar cross-sectional outer surfaceas shaft 104 when arms 120 are in the retracted position. This can bebeneficial when positioning arms 120 through an opening in the tissuebefore deployment. Advantageously, prior to deployment of arms 120,tissue locater 118 can have a cross section of about 7 Fr or less. Insome embodiments, tissue locater 118 can have a cross section of between5 and 30 French prior to deployment of arms 120. In some embodiments,tissue closure device 100 can have a cross-section of about 6 Fr or lessfor the entire device distal of the proximal end 112 of shaft 104.

End faces 158 are used to determine the location of the distal surfaceof the tissue. This can be done by positioning arms 120 through anopening in the tissue until the arms are distal of the tissue, deployingarms 120, and then pulling tissue locator 118 proximally until end faces158 contact the distal surface of the tissue. To aid in this, each endface 158 is substantially planar and extends from an outer edge 160 toan inner edge 162. Outer edge 160 is formed by the intersection of endface 158 with outer surface 154 and inner edge is formed by theintersection of end face 158 with inner surface 156. End face 158generally faces proximally and can be substantially orthogonal to outersurface 154 and/or inner surface 156, or can be at any desired anglewith respect to inner or outer surfaces 156 or 154. In the depictedembodiment, each end face 158 is formed so as to be substantiallyperpendicular to axis 122 when the corresponding arm 120 is in thedeployed position, as shown in FIG. 3C.

End faces 158 can be of any desired cross-sectional shape. In thedepicted embodiment, outer edge 160 of each end face 158 is in the shapeof an arc that substantially matches the diameter of shaft 104. Inneredge 162 extends from either end of outer edge 160 towards axis 122 andis substantially rounded off, as shown in FIGS. 3B and 3D. If desired,the innermost portion of each inner edge 162 can alternatively be shapedas a smaller arc of an inner circle, as depicted by dashed lines in FIG.3B, to provide more contact with expanders used to move arms 120 betweenthe retracted and deployed positions. Of course, other shapes can alsobe used.

A penetrator receptacle 164 can be formed on end face 158 of each arm soas to generally face proximally. As shown in the close-up view of FIG.3F, a releasable cuff 166 may be disposed within each penetratorreceptacle 164. As such, the penetrator receptacles can also be referredto as cuff pockets. A surface of each receptacle 164 can taperproximally and outwardly to guide advancing penetrators, such as, e.g.,needles or other elongated bodies, into engagement with cuffs 166positioned therein when arms 120 are in the deployed position, asdiscussed in more detail below.

When in the deployed position, penetrator receptacles 164 can define alateral width 168 (FIG. 3D) that can be in a range from about 0.10inches to about 0.612 inches, with about 0.110 inches to about 0.30inches being common. Other widths can also be used.

In one embodiment, penetrator receptacles 164 can each include a cuffrecess 170 into which cuffs 166 can be positioned. In one embodiment,each cuff recess 170 has a diameter about a centerline of cuff 166 ofabout 0.0230 inches and a length of about 0.042 inches. In someembodiments, penetrator receptacles 164 can taper outward at an anglebetween about 20 degrees and about 35 degrees from centerline. A lateralopening or window through the side of arm 120 to each cuff recess may beincluded to facilitate penetrator and/or cuff positioning duringassembly. A protruding collar may be positioned near the proximal end ofcuff recess to help keep cuff 166 in position. A slot may also bepositioned adjacent penetrator receptacle 164 to receive a suture orother filament, as discussed in more detail below.

Turning to FIG. 4, cuff 166 can be a roughly cylindrical structurehaving an axial channel 172 extending therethrough between a proximalend 174 and a distal end 176. A first slot 178 can be formed at proximalend 174 of cuff 166 to define at least one tab 180. Tabs 180 can be usedto aid in capturing a penetrator inserted into channel 172, as discussedbelow. A second slot 182 can be formed at distal end 176 of cuff 166 todefine a suture attachment collar 184. Suture attachment collar 184 canbe used to facilitate attachment of a suture or other filament to cuff166, also as discussed below. Cuff 166 can be comprised of a resilientmaterial, such as a metal or alloy. For example, in one embodiment, cuff166 can be comprised of stainless steel.

Returning to FIGS. 3A and 3C, tissue locator 118 can also include an armexpansion mechanism to help in moving arms 120 between the retracted anddeployed positions. For example, in the depicted embodiment, an armexpansion mechanism 186 can comprise an expander 188 that is moved alongaxis 122 by an actuator 190. Actuator 190 can extend proximally fromexpander 188 through a lumen 192 of shaft 104 or along the outsidesurface of shaft 104 and can be coupled to arm actuation handle 110 or134 (FIG. 1B or 2B). Actuator 190 can be a rod or the like. Other typesof actuators can alternatively be used.

In the depicted embodiment, expander 188 can comprise a substantiallyconical wedge extending distally from a base 194 to a substantiallynarrower distal end 196. When arms 120 are in the retracted position,expander 188 can be positioned within shaft 104 proximal of arms 120, asshown in FIG. 3A. Actuation of arm actuation handle 110 or 134 (FIG. 1Bor 2B) can cause actuator 190 to advance distally, as denoted by arrow198, thereby causing expander 188 to also advance distally. Eventually,distal end 196 of expander 188 contacts inner edge 162 of each arm endface 158. As expander 188 is advanced further distally by actuator 190,the expander begins to exert an outward force on arms 120 at inner edges162. Because distal end 152 of each arm 120 is attached to or formedwith shaft 104, however, distal end 152 cannot be moved radially outwardby the exerted force. On the other hand, proximal end 150 of each arm120 is unattached to shaft 104 and can therefore move radially outwardin response to the exerted force, pivoting about distal end 152 to doso. As a result, each arm 120 begins to pivot radially outward aboutdistal end 152.

Due to the wedge shape of expander 188, as expander 188 advances furtherdistally, the outward force exerted by expander 188 against inner edges162 causes each arm 120 to continue to pivot radially outward aboutdistal end 152. Proximal ends 150 of arms 120 can continue to be pushedradially outward by expander 188 until distal end 196 of expander 188reaches inner edges 162 of arms 120. At that point, proximal ends 150 ofarms 120 are in the deployed position shown in FIGS. 3C and 3D. As notedabove, in the deployed position, arms 120 can be used to locate thedistal wall of the tissue through the tissue opening, as discussed inmore detail below.

To move arms 120 back to the retracted position shown in FIGS. 3A and3B, arm actuation handle 110 or 134 (FIG. 1B or 2B) can be moved back toits original position, thereby causing actuator 190 to retractproximally. This causes expander 188 to also move proximally, therebyallowing the proximal end 150 of arms 120 to move radially back towardsaxis 122. To aid in moving arms 120 back to the retracted position, eacharm 120 can be made of a resilient material that biases the arm towardsthe retracted position. For example, arms 120 can be made of a resilientpolymer, metal, alloy, or the like. A shape memory alloy, such as, e.g.,a nickel titanium allow, commonly known as nitinol, can also be used.Alternatively, a biasing element, such as, e.g., a spring, can beattached between arms 120 to bias the arms to the retracted position.

In an alternative embodiment, expander 188 can be threaded. In thatembodiment, rotation of actuator 188 about axis 122 can cause expander188 to rotate. Due to the threaded connection with inner edges 162, thiscan cause expander 188 to move distally with respect to arms 120,thereby rotating arms 120 to the deployed position. If desired, to makethe threaded connection stronger, each inner edge 162 can also include aportion of a thread that mates with the thread on expander 188, asindicated by the dashed lines shown on FIG. 3B. To actuate the threadedexpander, a rotating arm actuation handle can be used.

FIGS. 5A-5D show an alternative embodiment of a tissue locater 200 thatallows for further lateral movement of the arms than tissue locater 118.Tissue locater 200 includes arms 202 a and 202 b that are substantiallylonger than arms 120, with an inner surface 204 of each arm being shapedto include a recess 206 between proximal and distal ends 150 and 152, asshown in FIG. 5A. Each recess 206 extends from a proximal end 208distally outward to an outer edge 210 and then inward to an inner edge212 at a distal end 214. Inner edge 212 is closer to axis 122 than isouter end 210. The recesses 206 of arms 202 combine to generally form acavity 216. Recesses 206 are shaped so that when arms 202 are in theretracted position, expander 188 can be positioned within cavity 216, asshown in FIG. 5A.

Similar to the embodiment described above, as expander 188 movesdistally, the outer surface thereof can contact and move inner edges 212laterally outward, thereby causing proximal ends 150 of arms to pivotradially outward about distal ends 152 until arms 202 are fullydeployed, as shown in FIGS. 5C and 5D. Because inner edges 212 of innersurface 204 are positioned distally of proximal end 150, and becausearms 202 are substantially longer than arms 120, proximal ends 150 ofarms 202 are moved substantially further radially outward when deployedthan are arms 120 (compare FIGS. 5C and 5D to FIGS. 3C and 3D).

Similar to the embodiment discussed above, expander 188 can besubstantially conically shaped. Alternatively, expander 188 can besubstantially cylindrically or rectangularly shaped as long as cavity216 is generally shaped to receive expander therein. Other expandershapes may also be possible.

FIGS. 6A-6D show an alternative embodiment of a tissue locater 230 thatuses an expander 232 that is moved proximally instead of distally todeploy the arms. Similar to the tissue locaters discussed above, tissuelocater 230 also includes arms 234 a and 234 b having penetratorreceptacles 164 on proximal end faces 158 thereof for receiving cuffs.On arms 234, a lower portion 236 of each inner surface 238 extendsinward toward axis 122 as inner surface 238 extends proximally fromdistal end 152 of arm 234, so as to generally form a ramp, as shown inFIG. 6A.

Unlike the expanders discussed above, expander 232 can be initiallypositioned distal of the distal end 152 of arms 234 when arms are in theretracted position, as shown in FIG. 6A. As expander 232 is withdrawnproximally, the outer surface thereof can contact the bottom portion oframp 236 of each arm 234. As expander 232 is withdrawn furtherproximally, expander 232 begins to exert an outward force on arms 234 atramps 236. As expander 232 is withdrawn further proximally, the outwardforce exerted by expander 232 on ramps 236 causes proximal ends 150 ofarms 234 to pivot outward about distal end 152 until arms 234 are fullydeployed, as shown in FIGS. 6C and 6D. As such, although variouscomponents of tissue locator 230 may be different than tissue locators118 and 200, discussed above, the result is the same; proximal ends 150of arms are caused to move from the retracted position to the deployedposition by actuation of the actuator.

Expander 232 is shown in the depicted embodiment as being substantiallycylindrical. However, similar to the expanders discussed above, expander232 can be substantially conical or rectangular if arms are modifiedaccordingly. Other expander shapes may also be possible.

Turning to FIGS. 7A-7C, which shows tissue locator 200, cuffs 166 can beused in conjunction with penetrators 136 to help position a loop ofsuture or other filament 264 across a tissue opening 250 to aid inclosing the opening. Each penetrator 136 can comprise a substantiallyrigid elongated shank 252 that extends to a distal tip 254. Penetrator136 can also include means for attaching the penetrator to the cuff. Themeans for attaching can provide a permanent attachment or a removableattachment, as discussed in more detail below. In the depictedembodiment, penetrator 136 comprises an elongated needle and the meansfor attaching the penetrator to cuff 166 comprises a barbed tip 256(FIG. 8) that provides a permanent attachment to cuff 166. Penetrators136 can be initially positioned within channels or lumens 258 defined inshaft 104 to carry the penetrators, as shown in FIG. 7A. Likewise, arms202 (202 a and 202 b) can be initially positioned in the retractedposition, as shown in FIG. 7A. Before using penetrators 136, arms 202should be moved to the deployed position shown in FIG. 7B. This can bedone by manipulating arm actuation handle 110, as discussed above.

As shown in FIG. 7A, penetrator guides 260 can be positioned at thedistal end of lumens 258 to laterally deflect penetrators 136 outward aspenetrators 136 are moved distally so penetrators 136 can extendlaterally to cuffs 166 of arms 202 when arms 202 are in the deployedposition. This lateral deflection of penetrators 136 can allow the useof a small diameter shaft 104, while still encompassing sufficienttissue within the suture loop on opposite sides of the tissue opening soas to effect hemostasis when the suture loop is tightened and secured.

In some embodiments, shaft 104 can comprise an outer casing of abiocompatible material such as stainless steel, carbon fiber, nylon,another suitable polymer, or the like. Penetrator guides 260 may bedefined at least in part as lumens formed within the casing of apolymeric material such as nylon or the like. In some embodiments, shaft104 may comprise a carbon-fiber filled nylon, or carbon fiber filledwith an alternative material.

As shown in the depicted embodiment, an end 268 of suture loop 264 canbe attached to each cuff 166. Opposite ends of the same suture can besecured to different cuffs 166, as in the depicted embodiment, or endsof different sutures can be used.

In one embodiment, suture 264 can comprise a continuous filament withone end 268 of the suture being attached to cuff 166 in penetratorreceptacle 164 of one arm 202 a and the other end 268 of the suturebeing attached to cuff 166 in penetrator receptacle 164 of the oppositearm 202 b. An intermediate portion 270 of suture 264 between the ends268 may extend proximally into shaft 104. In one embodiment,intermediate portion 270 can extend along a suture lumen of shaft 104 toproximal housing 102 or beyond. Alternatively, the intermediate portion270 of suture 264 between the ends 268 may extend distally within guidebody 116 or may be positioned external to shaft 104. In still furtheralternatives described below, a short length of suture or some otherflexible filament 264 may extend substantially directly between thepenetrator receptacles in the two arms.

To use penetrators 136 to help close tissue opening 250, arms 202 oftissue closure device 200 should be positioned through opening 250 andthen moved to the deployed position shown in FIG. 7B. This can be doneby manipulating arm actuation handle 110, as discussed above. As arms202 are moved to the deployed position, ends 268 of suture 264 also moveoutward due to the attachment of suture 264 to each cuff 166.

Upon actuation of penetrator actuation handle 106 (see FIGS. 1 and 2),penetrators 136 move distally and extend laterally from shaft 104 tosecurely engage with cuffs 166, as shown in FIG. 7C. Specifically,penetrators 136 advance from fixed penetrator guides 260, and arelaterally directed into cuffs 166 by receptacles 164.

In one embodiment, penetrator 136 comprises an elongated needle having abarbed end 256 defining a recessed engagement surface 262, as shown inFIG. 8. Channel 172 of cuff 166 can receive barbed end 256 of needle 136therein. Tabs 180 can be resiliently biased inward into channel 172. Asneedle 136 advances into cuff 166, barbed end 256 resiliently displacestab 180 clear of channel 172 so as to allow the barbed end to passaxially into cuff 166. Once barbed end 256 is disposed axially beyondtab 180, tab 180 can resiliently flex back into channel 172, therebycapturing needle 136 by engagement between tab 180 and recessed surface262. As each tab 180 can hold cuff 166 in place on needle 136, the useof more than one tab can increase the reliability of the system. Forexample, three tabs 180 can be provided on cuff 166, as illustrated inFIG. 4. Once needle 136 has been secured to cuff 166, the cuff can bewithdrawn proximally from arm 234 by withdrawing needle 136 proximallyback toward shaft 104. Other types of penetrators besides needles canalso be used with cuff 166, as discussed below.

Returning to FIG. 7C in conjunction with FIG. 8, each cuff 166 can begenerally configured to facilitate withdrawal of itself (and anyattached suture or filament 264) along with penetrator 136 axiallythrough the tissue wall 266 along the penetrator path. As such,penetrator 136 can comprise an elongated shank having a cross-sectionalwidth of between about 0.010 inches and about 0.020 inches, with otherwidths being possible. Engagement surface 262 formed by barb 256 canhave a protruding length of between about 0.002 inches and about 0.005inches, with other lengths being possible.

As shown in FIG. 8, cuff 166 can have a cross-sectional size roughlycorresponding to or slightly larger or smaller than penetrator 136. Inone embodiment, cuff 166 can have an outer lateral width of betweenabout 0.014 inches and 0.025 inches, and an axial length of betweenabout 0.035 inches and 0.050 inches. Channel 172 can be sized to receiveat least a portion of needle 136, and can generally have a width ofbetween about 0.010 inches and 0.020 inches, with other widths alsobeing possible. In the exemplary embodiment, penetrator 136 has adiameter of about 0.020 inches, while the cuff comprises a tube havingan outer diameter of about 0.020 inches, an inner diameter of about0.016 inches, and an overall length of about 0.047 inches. In someembodiments, the diameter of cuff 166 is based primarily on the diameterof suture 264 attached thereto. Weeping of blood can occur through thetissue hole created by penetrator 136 if the hole is substantiallylarger than the suture. As such, greater diameters can be used for cuff166 and penetrator 136 if a suture of a correspondingly greater diameteris used.

Penetrator 136 can have a length of between about 5.0 inches and 6.0inches, with other lengths also possible. Penetrator 136 can besufficiently stiff to be advanced in compression through the tissue wall(and adjacent tissues, if necessary) for up to about 0.5 inches whensupported in cantilever. Greater distances may also be possible.Penetrator 136 can also be substantially flexible to be laterallydeflected within shaft 104 by penetrator guide 260, as discussed above.Penetrator 136 can be comprised of a high strength metal, such as, e.g.,stainless steel. Other materials can also be used.

Cuff 166 can also comprise a flexible material to allow tab 180 to flexout of the way of barbed end 256, and to resiliently rebound and engagerecessed surface 262, as discussed above. In one embodiment, barbed end256 can have a diameter of about 0.015 inches, with the diameter of thepenetrator decreasing to about 0.008 inches proximally of the barb so asto define recessed engagement surface 262.

As noted above, an end 268 of suture or other filament 264 can beattached to each cuff 166. In the embodiment depicted in FIG. 8, the end268 of suture 264 is secured to the distal end of cuff 166 using suturecollar 184. Collar 184 may be crimped about suture 264 to mechanicallyaffix the suture to cuff 166. In addition and/or instead of mechanicalcrimping, the end of the suture may be bonded to cuff 166 using anadhesive, heat, fasteners, knots, or the like. In one embodiment, one orboth ends of the suture is enlarged to prevent the end from passingcompletely through the cuff. Other types of securing devices or methodscan also be used. Opposite ends of the same suture can be secured todifferent cuffs 166, as in the embodiment depicted in FIGS. 7A-7C, orends of different sutures can be used.

By being secured to cuff 166, the end 268 of suture 264 can also bewithdrawn proximally from arm 202 when the cuff is withdrawn proximallyby penetrator 136. As such, as cuffs 166 and associated portions ofsuture 264 are releasably supported in arms 202, needles 136 can bewithdrawn proximally so as to draw cuffs 166 and attached suture ends268 from arms 202 proximally into shaft 104. By extending axially fromcuff 166 opposite the open end of channel 172, drag may be minimizedwhen the suture is drawn proximally along the penetrator path.

As discussed above, cuffs 166 and suture 264 can be withdrawn proximallyfrom penetrator receptacles 164 by penetrators 136. Turning now to FIG.9, to avoid entanglement of suture 264 with penetrators 136, a slot 272can be formed in each arm 202 so as to extend laterally and proximallyfrom penetrator receptacle 164. Slot 272 can be sized to receive suture264 as suture 264 extends from cuff 166. As penetrators 136 pull cuffs166 axially from penetrator receptacles 164, suture 264 can be pulledfrom slots 272 and free from arms 202. Bending of suture 264 withinsuture slot 272 can also help hold cuff 166 in penetrator receptacle164. If desired, slot 272 can be sized to have a smaller cross-sectionthan barbed tip 256 so that the barbed tip is unable to enter slot 272,thereby avoiding entanglement between penetrator 164 and suture 264.

A variety of other features may be included in the arms, penetratorreceptacles, and/or penetrators to avoid tangling of the penetrators inthe suture as the penetrators are directed to the cuff. For example, asillustrated in FIG. 10A, a moveable flap 274 may extend over slot 272 sothat the advancing penetrator can slide along flap 274 toward the cuff,rather than entering slot 272 and engaging suture 264 directly. Flap 274may be affixed along one side of slot 272, with the other side of flap274 flexing into receptacle 164 to release suture 264 from slot 272 whenthe cuff and suture 264 are withdrawn by the penetrator.

In an alternative mechanism for avoiding entanglement of the penetratorwith the suture, slots 272 of penetrator receptacles 164 can extendsubstantially tangentially to the surface of the receptacle. As a resultof this tangential arrangement, a penetrator entering receptacle 164 canbe directed toward cuff 166 contained therein, but does not enter andadvance within the tangential slot 272 so as to become entangled withthe suture. Slots 272 may optionally extend laterally through the arm sothat the loop of suture can be pulled from one side of the shaft 104without interference.

Another alternative mechanism for avoiding entanglement between thesuture and the penetrator is illustrated in FIGS. 10B and 10C. Atwo-part penetrator 136 i can include an outer sheath 276 and an innercore 278. These parts of the penetrators can initially advance togetherinto the receptacles with penetrator core 278 retracted so that thepenetrator presents a smooth tapered tip, as illustrated in FIG. 10B. Ifdesired, the combined tip can be larger in diameter than the slotcontaining the suture. Once two-part penetrator 136 i is fullypositioned within the penetrator receptacle, penetrator core 278 may beextended axially to expose barbed tip 256 and recessed engagementsurface 262, as shown in FIG. 10C, and to secure the penetrator to thecuff within the penetrator receptacle.

A first method of using a tissue closure device having a tissue locatorto close an opening in tissue will now be explained with reference toFIGS. 11A-11G. For purposes of discussion, the method will be set forthwith reference to tissue locator 200. However, it is appreciated thatthe other tissue locators discussed or envisioned herein canalternatively be used in this or any of the methods presented herein.Initially, arms 202 are in the retracted position with cuffs 166 beingpositioned within penetrator receptacles 164, and penetrators 136 arewithdrawn within shaft 104 proximal of arms 202, as shown in FIG. 7A. Alength of suture 264 is provided with ends 268 of suture 264 attached toeach cuff 166 and the intermediate section 270 of suture 264 extendinginto shaft 104 proximal of arms 120. Alternatively, intermediate sectionof suture can extend into shaft 104 or guide body 116 distal of arms120, or can be positioned external to shaft 104, as discussed above.

Tissue locater 200 can be used to help close an opening in tissue, suchas an incision in a blood vessel. To do so, the distal end of shaft 104is advanced distally through a tissue tract 300 and through the opening250 in the vessel wall 266 while the arms are in the retracted position,as shown in FIG. 11A. This can be done in a number of ways. For example,after an endovascular procedure, a guide wire 302 and a guide body thathave been positioned through the opening 250 in vessel wall 266 can beused. Shaft 104 is advanced until tissue locater 200 has advancedthrough opening 250 and into the blood vessel 304 far enough that theproximal ends 150 of arms 202 are positioned distal of vessel wall 266,as shown in FIG. 11B. Shaft 104 can include a bleed-back lumen, as isknown in the art, to notify the operator that arms 202 have beenadvanced far enough for deployment.

Once arms 202 are positioned within the vessel lumen 304 (i.e., distalof vessel wall 266), arms 202 can be deployed and used to “locate” theinner surface 306 of vessel wall 266 surrounding opening 250. To do so,the expander is moved to contact and produce a laterally outward forceon arms 202 by actuation of the arm actuation handle, as discussedabove. This causes the proximal ends of arms 202 to rotate radiallyoutward to the deployed position in the manner discussed above, on thedistal side of the vessel wall 266, as shown in FIG. 11C. Using tissuelocator 200, the expander is moved distally when actuated, as discussedabove. It is appreciated that with other embodiments of tissue locators,the expander may instead be moved proximally to provide the laterallyoutward force for moving the arms to the deployed configuration, asdiscussed above.

Once arms 202 have been fully deployed, shaft 104 can be gently pulledproximally until the penetrator receptacles 164 formed on arm faces 158are drawn proximally against the inner surface 306 of vessel wall 266 onopposite sides of opening 250, as shown in FIG. 11C. See also FIG. 7B.Not only do arms 202 help to accurately position the penetratorreceptacles on the distal surface 306 of the tissue wall 266, they alsohelp to position the penetrator guides at a predetermined proximaldistance from the tissue.

Once the arm faces are drawn proximally against the inner surface 306 ofvessel wall 266, penetrators 136 can be extended to arms 202, as shownin FIG. 11D. To do this, penetrators 136 are advanced distally andlaterally from channels or lumens in shaft 104 through penetrator guidesby actuation of the penetrator actuation handle, as discussed above.

The distal tips of penetrators 136 form penetration paths 308 in vesselwall 266 on opposite sides of opening 250 as penetrators 136 advancedistally therethrough. As the distal ends of penetrators 136 advance toarms 202, the tapering surfaces of the receptacles help to pushpenetrators 136 into alignment with the cuffs in arms 202 so as toovercome any unintended deflection of penetrators 136 by surroundingtissue 310 or vessel wall 266. This ensures that the means for attachingeach penetrator 136 to the corresponding cuff engages the cuff withineach receptacle, as discussed above, thereby coupling the ends 268 ofsuture 264 to the penetrators. In the present method, the means forattaching the penetrator to the cuff comprises the barbed tip to providea permanent attachment between the penetrator and the cuff.

As discussed above, the middle portion 270 of suture 264 can bepositioned within a shaft 104 proximal of arms 202. Alternatively, thesuture loop can instead extend distally from arms in a lumen of shaft104 or guide body, can be routed through the arms, and/or can bepositioned external to the shaft and guide body. Other suture paths canalso be used. Regardless, suture 264 should be configured to pull freeof the tissue closure device between the ends of the suture to form acontinuous loop across opening 250. The amount of suture 264 betweenarms 202 can vary.

Penetrators 136 can then be used to pull suture 264 proximally throughvessel wall 266, as shown in FIG. 11E. To do so, penetrators 136 arewithdrawn proximally through penetration paths 308 in vessel wall 266 bymoving penetrator actuation handle 106. Due to the secure engagement ofpenetrators 136 and suture 264 to cuffs 166, the withdrawal ofpenetrators 136 causes cuffs 166 and the ends 268 of suture 264 to alsobe drawn proximally through vessel wall 266 along penetrator paths 308formed by penetrators 136. As ends 268 of suture 264 move proximallythrough vessel wall 266, a portion of the intermediate section 270attached to ends 268 is also pulled proximally through penetrator paths308.

After the ends 268 of suture 264 have been withdrawn proximally throughvessel wall 266 and into shaft 104 by penetrators 136, tissue locater200 can be removed. To do so, arms 202 are moved back to the retractedposition shown in FIG. 11F by moving the expander using arm actuationhandle 110. This causes the expander to no longer produce a lateraloutward force on arms 202, which allows the proximal ends of arms 202 torotate inward to the retracted position. If needed, tissue closuredevice 200 can be moved slightly distally away from inner surface 306 ofvessel wall 266 before retraction of arms 202 so the arms can move tothe retracted position more easily. Using tissue locator 200, theexpander is moved proximally to allow arms 202 to rotate back to theretracted position. It is appreciated that with other embodiments oftissue locators, the expander may instead be moved distally to allow thearms to rotate back to the retracted position, as discussed above.

With arms 202 in the retracted position, shaft 104 can be withdrawnproximally through tissue tract 300 and removed therefrom. This causestissue locater 200 to also move proximally back through opening 250 tobe withdrawn from tissue tract 300. The withdrawal of tissue closuredevice 200 also causes the ends 268 of the suture loop 264, which arestill secured to needles 136, to continue to be proximally withdrawn. Asthe suture ends 268 are withdrawn, more of the intermediate section 270of the suture 264 is pulled proximally through penetrator paths 308 onboth sides of opening 250. If any of the intermediate portion 270 ofsuture 264 is originally positioned proximal of vessel wall 266, thatportion passes distally through opening 250 before being pulled backproximally through penetrator paths 308 in vessel wall 266.

Once shaft 104 has been withdrawn sufficiently, suture 264 can be usedto close opening 250. To do so, ends 268 of the suture 264 can begrasped by the operator and pulled proximally to pull the remainingsuture loop 264 proximally through penetrator paths 308 on the oppositesides of opening 250 to close the opening, as shown in FIG. 11G. A knotor closure device can then be used to secure suture 264 to allow theclosure of opening 250 to become permanent, as is known in the art.

FIGS. 12A-12D show an alternative, second, method of using tissuelocator 200 to close the tissue opening. In the alternative method,rather than pulling the two opposite ends of an extended loop throughthe needle paths and proximally out the tissue tract for tying, tissueclosure device 200 advances a single end of suture distally along oneneedle path, across the opening, and then proximally out along the otherneedle path.

Similar to the first method, shaft 104 is advanced through opening 250until the proximal ends 150 of arms 202 are positioned distal of thevessel wall 266, whereupon arms 202 are deployed and moved into contactwith the inner, or distal, surface 306 of vessel wall 266 surroundingopening 250, as shown in FIG. 12A. Also similar to the first method,each penetrator receptacle 164 contains a cuff 166 having attachedthereto an end 268 of suture or filament 264. However, instead of twoends of a long suture being attached to the cuffs, suture or connectingfilament 264 is short and spans substantially directly betweenpenetrator receptacles 164 to attach to cuffs 166, as shown in schematicin FIG. 12A. As such, connecting suture or filament 164 forms a linkbetween cuffs 166.

Similar to the first method, each penetrator 136 includes means forattaching the penetrator to the cuff. However, while one of thepenetrators includes a means for attaching that is permanent (e.g., thebarbed tip), the other penetrator includes a means for attaching that isreleasable. For ease of description, the penetrator having the means forpermanent attachment will be referred to as the “first” penetrator andthe penetrator having the means for releasable attachment will beidentified as the “second” penetrator herein and the identifiers thereofwill be respectively differentiated with an “a” and a “b” appended tothe identifier. Thus, the first penetrator and second penetrators 136will be respectively identified as 136 a and 136 b. The cuffs,penetrator receptacles, penetrator paths, etc. associated with eachpenetrator will likewise be referred to as “first” and “second” cuffs,penetrator receptacles, penetrator paths, etc and be differentiated inthe same manner (i.e., with an “a” or “b” appended to the identifier) asthe penetrators.

To facilitate separation of the second penetrator 136 b from the secondcuff 166 b, second penetrator 136 b includes a detachable couplingstructure that allows penetrator 136 b to separate from the second cuff166 b when the penetrator is withdrawn therefrom. For example, in thedepicted embodiment, the distal end of second penetrator 136 b comprisesa detachable tip 314.

A suture loop 316 having two ends 318 and 320 is positioned within orproximal of shaft 104, as shown in schematic. The first end 318 ofsuture 316 is releasably attached to second penetrator 136 b using thedetachable coupling structure so that suture 316 can separate fromsecond penetrator 136 b when second penetrator 136 b is withdrawn fromsecond cuff 166 b. For example, in the depicted embodiment, the firstend 318 of suture 316 is attached to detachable tip 314. Secondpenetrator 136 b may be hollow so that suture 316 may extend proximallywithin the hollow penetrator where the penetrator has an open channelalong its length, may exit the hollow penetrator just proximally ofdetachable tip 314, or may be disposed alongside a solid penetrator.

Similar to the first method, both penetrators 136 are advanced distallythrough tissue wall 266 to become attached to cuffs 166, as shown byarrows 322 in FIG. 12B. Because of its attachment to second penetrator136 b, the first end 318 of suture 316 is also advanced proximallythrough tissue wall 266 and secured to second cuff 166 b along withsecond penetrator 136 b.

When penetrators 136 a and 136 b are subsequently withdrawn proximallyfrom arms 202, as indicated by direction arrows 324 in FIG. 12C, suture316 advanced through tissue wall 266 with second penetrator 136 bremains attached to second cuff 166 b with the detachable tip. Firstcuff 166 a remains secured to first penetrator 136 a, as in the firstmethod, and is withdrawn proximally therewith. As link 264 extendsbetween cuffs 166 a and 166 b, and as detachable tip 314 can pull freeof second penetrator 136 b when the penetrators are withdrawn, thiseffectively couples first penetrator 136 a to first end 318 of suture316.

Thus, as first cuff 166 a is withdrawn proximally through firstpenetrator path 308 a as indicated by directional arrow 324, link 264between cuffs 166 a and 166 b is drawn across the tissue opening, asindicated by directional arrow 326, and also withdrawn proximallythrough first penetrator path 308 a. Because of its attachment to link264, second cuff 166 b, along with suture 316 now attached thereto, arealso drawn across the tissue opening, as indicated by directional arrow328.

As shown in FIG. 12D, as the first and second penetrators are furtherwithdrawn proximally, second cuff 166 b is withdrawn proximally throughfirst penetrator path 308 a and out of the body, as indicated bydirectional arrow 330, by virtue of the attachment of second cuff 166 bto link 264. As a result, suture 316, which is attached to second cuff166 b, is pulled distally through second penetration path 308 b, asindicated by directional arrow 332, across the tissue opening, asindicated by directional arrow 334, and then back proximally throughfirst penetration path 308 a, as indicated by directional arrow 336.

As a result, rather than pulling both ends of an extended loop throughthe penetrator paths and proximally out the tissue tract for tying as isdone in the first method, a single end of suture attached to the secondcuff advances distally through the second penetrator path, across thetissue opening, and then proximally along the first penetrator path asthe penetrators are withdrawn.

Once the first end 318 of tissue 316 has been withdrawn proximallythrough first penetration path 308 a, arms 202 can be moved to theretracted position and tissue closure device 200 can be removed from thetissue tract. A knot or closure device can then be used to secure thesuture 316 to allow the closure of the tissue opening to becomepermanent.

The second method is especially useful for using a pre-tied knot toclose the tissue opening. For example, turning to FIG. 13A, a bight 340of suture 316 can be releasably attached to the shaft encircling theopening of penetrator guide 260 (see FIG. 12A) of the fixed tippenetrator. The bight 340 of suture 316 may be releasably disposedwithin a slot of the shaft, may be temporarily held in place by a weakadhesive or coating, or the like. The second end 320 of suture 316 canextend proximally along the shaft and can also be releasably held alongthe shaft, if desired.

Bight 340 can define a knot when the first end 318 of suture 316 passestherethrough, as can be understood with reference to FIGS. 12A-12D.Bight 340 can include one or more loops, and can be pre-arranged so asto define a square knot using the general layout illustrated in FIG.13A, a cinch knot using the general layout illustrated in FIG. 13B, or avariety of known or new surgical knots.

The knot can be completed by pulling second penetrator 136 b, shortsuture 264, and first end 318 of suture 316 (together with cuffs 166 aand 166 b and detachable first penetrator tip 314) proximally throughbight 340. Second end 320 of suture 316 can be pulled to free bight 340,and the ends 318 and 320 of suture 316 can be tightened and the tissueclosure device removed to provide permanent hemostasis.

In an alternative embodiment of tissue closure device 200, a slot can beincluded, distal of arms 202, that includes a passage that defines asuture bearing surface through which link 264 and second cuff 166 b canpass. Instead of link 264 attaching directly between first and secondcuffs 166 a and 166 b across the tissue opening, an intermediate portionof the link can be positioned within the passage. Then, when thepenetrators are withdrawn proximally, the link, the second cuff, and thesuture can all pass through the passage before being withdrawnproximally through the first penetrator path.

Using a passage can provide some unique benefits. For example, thesuture bearing surface can bear forces placed on the suture duringsuturing. As such, the suture-bearing surface can minimize forces placedon an incision during incision tensioning, thereby minimizing thepossibility of damaging tissue immediately surrounding the incision.

FIGS. 14A and 14B show one embodiment of a suture bight 342 that can beused with suture link 264. FIG. 14A depicts suture bight 342 in apre-deployed state and FIG. 14B depicts suture bight 342 in a deployedstate. As the suture link 264 and the suture 316 move, a pre-tied sutureknot 344 can also move in the same direction as the suture loop 264, asindicated by directional arrow 346. Suture loop 264 can continue to movepre-tied suture knot 344 towards the incision until suture 316 andpre-tied suture knot 344 close the incision formed in the vessel wall.

Suture 316 can be arranged to provide the pre-tied knot 344 thatautomatically travels down from the shaft of the tissue closure devicewhere the knot can be stored prior to delivery to the tissue wall. Thesuture loop 264 can serve to pull knot 344 down a rail portion 348 ofsuture 316 during deployment. If desired, the ends 318 and 320 of suture316 can be differentiated from each other so the operator candistinguish them and pull the correct end to advance and tighten theknot.

FIGS. 15A-D illustrate a method of attaching suture 316 to cuff 166 andreleasing cuff 166 from arm 202 using penetrator 136. As such, theillustrated method can be used to attach suture 316 to the second cuff166 b using second penetrator 136 b in the second method discussedabove. Penetrator 136 may be any type of structure capable ofpenetrating the wall of a lumen, such as an artery, a blood vessel, orthe like. In addition to the penetration capability, the penetrator mayincorporate a hollow tube capable of holding suture. Examples of suchstructures may include a hypodermic needle or the like. As discussedabove, in many embodiments the tissue locator can store penetrator 136within its shaft, as shown in FIG. 7A. As previously described withreference to FIGS. 2A through 2C, a user can deploy a handle of thesuturing device to deploy penetrator shank 252 and its correspondingpenetrator tip 256. During deployment, penetrator shank 252 andpenetrator tip 256 penetrate the lumen wall 266 immediately surroundingthe incision or other tissue opening, as shown in FIG. 15A.

Penetrator 136 is advanced through lumen wall 266 until penetrator tip256 engages with cuff 166, which is positioned within cuff recess 170.Once penetrator tip 256 engages with cuff 166, the penetrator can befurther advanced so that penetrator tip 256 advances cuff 166 furtherinto arm 202, as shown in FIG. 15B. As may be seen with reference toFIG. 15B, cuff 166 can be thereby dislodged out of pocket 170 (FIG. 15A)and into a lumen in arm 202. Once cuff 166 has been dislodged frompocket 170, a push mandrel 350 can be used to detach penetrator tip 256from penetrator shank 252 as shown with reference to FIG. 15C.

FIG. 15C illustrates the detachment of penetrator tip 256 frompenetrator shank 252 in accordance with one embodiment of the presentinvention. Upon engagement of penetrator tip 256 with cuff 166, pushmandrel 350 is further advanced such that it contacts proximal surface262 of penetrator tip 256, and further still until penetrator tip 256detaches from penetrator shank 252.

As shown in FIG. 15D, after penetrator tip 256 detaches from penetratorshank 252, penetrator shank 252 retracts from penetrator tip 256 andcuff 166, leaving suture 316 attached to cuff 166. Then, when suturelink 264 is pulled across the tissue opening by the penetrator on theother side of the tissue locator (not shown), cuff 166 and attachedsuture 316 will follow, as discussed in the second method above.

FIGS. 16A and 16B illustrate an alternative embodiment for releasingcuff 166 from arm 202. In this embodiment, arm 202 includes linkpassageway 352 through which link 264 passes. After penetrator shank 252engages penetrator tip 256 with cuff 166, penetrator shank 252, duringretraction from arm 202, removes cuff 166 and penetrator tip 256 fromthe arm. The force holding penetrator tip 256 on penetrator shank 252overcomes the force holding cuff 166 in cuff pocket 170. Once cuff 166clears arm 202 and attains the orientation shown with reference to FIG.16B, the previously described push mandrel (not shown) can detachpenetrator tip 256 from penetrator shank 252. Upon detachment ofpenetrator tip 256 from penetrator shank 252, cuff 166 and attachedsuture 316 are free to be pulled across the tissue opening by link 264,as discussed above. In an alternate embodiment, cuff 166 and penetratortip 256 may be pulled off elongated shank 252 by tension in link 264.Alternatively, cuff 166 and penetrator tip 256 may be detached frompenetrator shank 252 before being removed from cuff pocket 170.

Alternative cuff configurations may be used that facilitate engagementof penetrator bodies 252 with link 264. For example, FIG. 17Aillustrates a perspective view of an alternative embodiment of apenetrator tip 354 that can be used with cuff 166. In this embodiment,penetrator tip 354 includes windows 356 with proximal facing matingsurfaces 358 which engage with tabs 180 of cuff 166 when penetrator tip354 engages with cuff 166, as shown in FIG. 17B. As such, a user candetach penetrator shank 252 from penetrator tip 196 with push mandrel350 after engagement of penetrator tip windows 356 with cuff tabs 180,as discussed with reference to penetrator tip 256 and cuff 166.

FIGS. 18A-C show an alternative method of coupling penetrator shank 252with link 264. In this embodiment, penetrator shank 252 includes a loop360 which engages with link 264 as penetrator shank 252 enters arm 202.To facilitate the engagement, link 264 is constructed of a resilientmaterial capable of flexing in response to loop 360 contacting link 264,such as polypropylene or any other material having spring-likecharacteristics.

As shown in FIG. 18A, penetrator shank 252 moves distally into arm 202in the direction indicated by directional arrow 362 until loop 360 comesinto contact with an end 268 of link 264. When loop 360 contacts the end268, loop 360 moves the end 268 in the direction indicated bydirectional arrow 364. As penetrator shank 252 continues to distallyadvance, loop 360 continues to move the end 268 of link 264 in thedirection 364 until loop 360 advances beyond the end 268 of link 264.

As noted above, link 264 can be constructed of a material having springlike properties. As such, when loop 360 advances beyond the end 268 oflink 264, the resilient properties of link 264 move the end 268 in thedirection indicated by directional arrow 368 in FIG. 18B. The end 268 oflink 264 moves in the direction 368 such that the end 268 of link 264moves into loop 360, as shown in FIG. 18B. Once the end 268 of link 264moves into loop 360, loop 360 can be retracted into the penetrator shank252 in the direction indicated by directional arrow 370. In someembodiments the end 268 of link 264 also moves into penetrator shank 252with loop 360. In some embodiments, the end 268 of link 264 remainsoutside of penetrator shank 252.

As shown in FIG. 18C, as loop 360 moves in the direction 370, loop 360clamps link 264 against a surface 372 of the elongate shank 252. As aresult, during retraction of the penetrator from arm 202, link 264remains engaged with penetrator shank 252. As penetrator shank 252 andloop 360 retract from arm 202, loop 360 pulls link 264 throughpenetrator path 308, as shown in FIG. 18C. While loop 360 pulls link264, cuff 166 (not shown) and the suture 152 (not shown) also can movethrough penetrator path 308 in order to enable closure of a tissueopening.

In another embodiment, the suturing device 150 may also employ a clipand ring assembly 374 to couple the penetrator bodies 252 with link 264,as shown with reference to FIGS. 19A-G. FIGS. 19A and 19B illustrateclip and ring assembly 374 in an attached configuration. Clip and ringassembly 374 comprises a clip 376 and a ring 382 that engages with clip376. Each clip 376 can include flexible arms 378 and a passageway 380between the arms 378. Ring 382 can have a circular configuration asshown with respect to FIG. 19B. Initially, the clip 376 can beincorporated into penetrator shank 252 in place of penetrator tip 256 orneedle tip 314. Alternatively, clip 376 can be initially positionedwithin penetrator 252 and extendable therefrom, as shown in FIGS. 19Cand 19D. Ring 382 can initially be positioned within arm 202 and coupledto link 264, as shown in FIG. 19E. Link 264 can couple with the ring 382using any suitable technique, such as tying or the like.

As shown in FIG. 19E, as the elongate shank 252 engages with arm 202,clip 376 can be advanced, as indicated by arrow 383, to couple with ring382. As illustrated in FIG. 19F, as clip 376 engages with ring 382,flexible arms 378 flex in a direction indicated by directional arrows Yand Z thereby increasing a width W_(i) of passageway 380 in order toallow passage of ring 382 through passageway 380 of clip 376.

Referring to FIG. 19G, there is shown a top view of end face 158 of arm202 where arm 202 can include a cuff pocket 384 having a pair ofelongated openings 386 and 388 that intersect in the middle to form across. Cuff pocket 384 holds ring 382 such that ring 382 is generalpositioned in opening 386 prior to engagement with clip 376. Cuff pocket384 is configured such that as penetrator shank 252 engages arm 202,clip 376 can enter opening 388 and engage with ring 382 as shown. Onceclip 376 engages with ring 382, ring 382, which is coupled with link264, can detach from cuff pocket 384 while penetrator shank 252 remainsengaged with clip 376.

FIG. 20 shows an embodiment of a cuff and link assembly that may be usedwith various embodiments. Cuff 390 has a penetrator tip receiving end392 and a tapered end 394. Link 396 has two ends 398 (only one shown inFIG. 20). An example of a preferred link material is expandedPolytetrafluoroethylene (ePTFE), more commonly referred to as teflon.ePTFE is particularly suited for use as the link material in the vesselclosure devices described herein because of its low friction, highstrength properties.

To assemble the link and cuff assembly, a length of link 396 is firstthreaded through cuff 390. The end 398 of link 396 extending frompenetrator tip receiving end 392 of cuff 390 is then heated so that end398 of link 396 expands. Link 396 is then pulled through cuff 390 suchthat the expanded end portion 398 is seated in the interior tapered end394 of cuff 390.

In some embodiments it may be advantageous to provide multiple sutureloops across the tissue opening. For example, closure of a large openingmay require two three or more pairs of loops. To accommodate this,tissue closure devices can incorporate more than two arms.

Tissue locators envisioned herein may contain any number of arms. Forexample, tissue locators having four, six, eight, ten or more arms arepossible. Independent of the number of arms, all of the arms can beessentially identical and positioned on the tissue locator so as to beradially spaced about the tissue opening. The arms can be equidistantlyplaced about the tissue opening or can have varying distances betweenthem.

By using more arms, multiple suture links can be formed using the cuffsin the arms. For example, for any even number of arms, a number of linksequal to half the number of arms can be formed, where each link spansbetween two of the cuffs. For example for tissue locators having four,six, eight, and ten arms, two, three, four, and five links can beformed, respectively. The links can be formed between diametricallyopposed cuffs or between any of the cuffs, as discussed below. Each linkand corresponding cuffs can be employed in any of the manners discussedabove.

FIGS. 21A through 21D show one embodiment of a tissue locator 400 thatincorporates four arms. Tissue locator 400 is similar to tissue locator200 (see FIGS. 5A-5D), except for the additional arms. That is, similarto tissue locator 200, tissue locator 400 has a pair of arms 402 a and402 b diametrically opposed to each other with respect to central axis122. However, unlike tissue locator 200, tissue locator 400 also has asecond pair of arms 402 c and 402 d, also diametrically opposed to eachother with respect to central axis 122. As such, there are four arms 402arranged radially about central axis 122, as particularly shown in FIGS.21B and 21D. Similar to the embodiments discussed above, each arm 402can include a penetrator receptacle 164 and a cuff 166 releasablypositioned therein. Also similar to the tissue locators discussed above,each arm 402 can pivot about its distal end 152 between the retractedposition, as shown in FIGS. 21A and 21B, and the deployed position shownin FIGS. 21C and 21D by distal movement of expander 188.

FIGS. 22A through 22D show another embodiment of a tissue locator 410that incorporates four arms 412 (412 a-412 d). Tissue locator 410 issimilar to tissue locator 400, except that instead of using expander 188to deploy the arms, tissue locator 410 uses expander 232 that is movedproximally instead of distally to deploy the arms, similar to tissuelocator 230 (see FIGS. 6A-6D). As such, similar to arms 234 of tissuelocator 230, arms 412 are initially in a retracted position, as shown inFIGS. 22A and 22B, and can be pivoted laterally outward to the deployedposition by proximal movement of expander 232, as shown in FIGS. 22C and22D.

Tissue locators 400 and 410 can be used with any of the tissue closuredevices discussed or envisioned herein and penetrators 136 can beemployed therewith in any of the manners discussed above. To takeadvantage of all four arms 402 or 412, four penetrators 136 can bepositioned within shaft 104, with each penetrator 136 beingsubstantially aligned with one of the arms so as to be able to advanceinto the four cuffs. Although only two and four arms have been discussedherein, it is appreciated that more than four arms can also be used,along with the same number of corresponding cuffs, penetrators, etc.

In many respects, a tissue closure device with four arms works in asimilar manner as a tissue closure device with only two arms, such asthose discussed above, except for the use of the four arms instead oftwo. For example, regardless of the number of arms used, the tissuelocator can be inserted through the tissue opening with the arms in theretracted position; the arms can be deployed and positioned against thedistal wall of the tissue; the penetrators can be advanced through thetissue wall until attached to the cuffs and thereafter withdrawn; suturelinks and/or the cuffs can be withdrawn with the penetrators; the armscan be retracted back to the retracted position so that the tissueclosure device can be withdrawn from the tissue opening, and thewithdrawn suture can can be used to seal the tissue opening.

However, tissue closure devices having more than two arms can provideunique benefits over those that do not, and these benefits will bediscussed below. For ease of discussion, reference numeral “500” will beused to delineate the arms when referring to the multiple arms below. Inaddition, each arm 500 will be referred to as “first” arm, “second” arm,“third” arm, “fourth” arm, etc., in a clockwise manner about centralaxis 122. Each penetrator, penetrator receptacle, cuff, etc. thatcorresponds with the particular arm 500 will also be referred to usingthe same identifier (e.g., “first”, “second”, “third”, and “fourth”). Tohelp in the drawings, each of the items may also include a lower-caseletter, appended to the reference numeral, corresponding to theidentifier, with “a” representing the “first” identifier, “b”representing the “second” identifier, and so forth. Thus, the first,second, third, and fourth arms will have designations of “500 a”, “500b”, “500 c”, and “500 d”, as shown in FIGS. 21B and 22B.

As noted above, a penetrator 136 can be associated with each of the fourarms 500. In some embodiments, penetrators 136 can be “paired” by beingassociated with a pair of cuffs linked together by a suture link in asimilar manner to the embodiments discussed above. For example, if firstand third cuffs are linked together by a suture link and second andfourth cuffs are linked together by a separate suture link, then firstand third penetrators are considered to be paired with each other andsecond and fourth penetrators are considered to be paired with eachother.

In some embodiments, each penetrator pair can be advanced and/orwithdrawn independently from the other linked penetrator pairs. In otherembodiments, each penetrator can be advanced and/or withdrawnindependently from the other penetrators. To facilitate these options,the tissue closure device can have a plurality of penetrator actuationhandles. Alternatively, the penetrator actuation handle can be dividedinto different portions, one for each penetrator or penetrator pair.

For example, FIGS. 23A-D show an embodiment of a penetrator actuationhandle 502 that can be used with either of tissue closure devices 410 or412. As shown in FIG. 23A, penetrator actuation handle 502 can bedivided into four separate penetrator actuators 504 (504 a-504 d). Eachpenetrator actuator 504 can be coupled with one of the penetrators 136so as to direct the movements of the respective penetrator 136. Forexample, first, second, third, and fourth penetrator actuators 504 a,504 b, 504 c, and 504 d can be respectively attached to first, second,third, and fourth penetrators 136 a, 136 b, 136 c, and 136 d.

When it is desired to advance or withdraw a particular penetrator, thepenetrator actuator corresponding to the desired penetrator can beadvanced or withdrawn, respectively. For example, to advance firstpenetrator 136 a distally without advancing the other penetrators, firstpenetrator actuator 504 a can be distally advanced, as shown in FIG.23B. If two or more penetrators are to be moved concurrently, such as,e.g., any paired penetrators, penetrator actuators 504 corresponding tothe desired penetrators can be used. For example, to concurrentlyadvance first and fourth penetrators 504 a and 504 d distally, first andfourth penetrator actuators 504 a and 504 d can be advanced, as shown inFIG. 23C. If all of the penetrators are to be moved concurrently, all ofthe penetrator actuators can be used. For example, to advance all of thepenetrators distally at the same time, penetrator actuators 504 a-504 dcan be advanced, as shown in FIG. 23D. Penetrator actuation handle 502can be adapted to be used with any number of arms by simply dividing thehandle 502 into the desired number of penetrator actuators 504. Otherpenetrator actuators can also be used.

FIGS. 24A-32C are schematic representations that illustrate examples ofvarious link combinations and link nets that can be used to close tissueopenings according to the present invention. In the examples, the endsof each link can extend into a cuff disposed within a penetratorreceptacle in any of the manners discussed above. To close the tissueopenings with any of the following link combinations and link nets,penetrators can be used in any of the manners discussed above to attachto the cuffs and pull the links proximally out of the body where theycan be tightened, then tied off or clipped.

Although each link in FIGS. 24A-32C is shown as extending in a generallyshortest route between cuffs or between cuff and hub, Applicant notesthat those figures are schematic representations to illustrate aparticular manner of link and that the actual links may instead belonger and may take a circuitous route between the respective cuffs, ifdesired, similar to the various embodiments discussed above.

FIG. 24A illustrates one embodiment of a link combination 510 that canbe used with tissue closure devices having four arms, such as tissuelocators 400 and 410, discussed above. Link combination 510 includes twolinks 512 and 514 whose ends are attached to different cuffs. Links 512,514 can cross each other as they span across tissue opening 250 to linkdiametrically opposed cuffs. For example, in the depicted embodiment thefirst and third cuffs 166 a and 166 c are linked by first link 512 andthe second and fourth cuffs 166 b and 166 d are linked by second link514. As such, correspondingly formed loops 512′ and 514′ can intersectacross tissue opening 250 in a cross pattern when the opening 250′ isclosed thereby, as illustrated in FIG. 24B. Although first and secondlinks 512 and 514 intersect each other, they can be unattached to eachother and therefore free to longitudinally move independent of eachother.

FIG. 25A illustrates another embodiment of a link combination 520 thatcan be used with tissue closure devices having four arms. Similar tolink combination 510, link combination 520 includes two links 522 and524 whose ends are attached to different cuffs. However, instead ofbeing attached to diametrically opposed cuffs, the ends of each link522, 524 attach to cuffs on adjacent arms. For example, in the depictedembodiment the first and second cuffs 166 a and 166 b are linked byfirst link 522 and the third and fourth cuffs 166 c and 166 d are linkedby second link 524. As such, correspondingly formed loops 522′ and 524′can span across tissue opening 250 without intersecting each other whenthe opening 250′ is closed thereby, as illustrated in FIG. 25B. Linkcombination 520 may be especially useful for closing openings that areelongated, but may be used to close any type of tissue opening.

Alternatively, first and second links 522 and 524 can cross over eachother as each link extends between its respective cuff, as depicted inlink combination 530 in FIG. 26A. In particular, first and second links522 and 524 can be looped through each other, as shown in FIG. 26A. Assuch, the correspondingly formed loops 522″ and 524″ can pull laterallyagainst each other when tightened to close tissue opening 250″, asillustrated in FIG. 26B. Similar to links 512 and 514, first and secondlinks 522 and 524 can be unattached to each other and therefore free tolongitudinally move independent of each other in either embodiment.

As noted above, each linked cuff pair can be attached to a differentsuture loop which can be closed about tissue opening 250 using one ormore of the methods discussed above. For example, for link combinations510, 520, and 530 shown respectively in FIGS. 24A, 25A, and 26A, oncearms 500 have been deployed and positioned against the distal surface ofthe tissue, any of the methods discussed herein can be performed for anyof the links.

For example, for the embodiment shown in FIG. 24A, any of the methodscan be employed using linked first and third cuffs 500 a and 500 c andcorresponding first and third penetrators to pull the corresponding link512 proximally through the tissue and any of the methods can be employedusing linked second and fourth cuffs 500 b and 500 d and correspondingsecond and fourth penetrators to pull the corresponding link 514proximally through the tissue. In some embodiments, the same method canbe used for both linked cuff pairs, and in other embodiments, differentmethods can be used for each linked cuff pair.

As discussed above, once links 512 and 514 have been pulled through thetissue, the corresponding suture loops can be tightened about tissueopening 250 to close the opening as shown in FIG. 24B. In a similarmanner, the linked cuff pairs shown in FIGS. 25A and 26A can also beattached to suture loops to tighten about and close tissue opening 250using any of the methods discussed herein.

The methods can be employed in parallel (i.e., the pairs of penetratorscorresponding to each linked cuff pair being advanced and subsequentlywithdrawn concurrently) or serially (i.e., each pair of penetratorsbeing advanced and subsequently withdrawn at different times from eachother) using, e.g., penetrator actuators 504 shown in FIGS. 23A-23D.

It is appreciated that the above discussion of suture links can beadapted to be used with any number of suture links. For example, FIG.27A illustrates one embodiment of a link combination 530 that can beused with a tissue closure device having six arms. Link combination 530includes three links 532, 534, and 536 whose ends are attached todifferent cuffs. First link 532 spans between diametrically opposedcuffs, while links 534 and 536 span between cuffs on either side offirst link 532. Specifically, first link 532 spans between first andfourth cuffs 166 a and 166 d, second link 534 spans between second andsixth cuffs 166 b and 166 f, and third link 536 spans between third andfifth cuffs 166 c and 166 e, as depicted in FIG. 27A. As a result,correspondingly formed loops 532′, 534′, and 536′ can close tissueopening 520′ in the manner illustrated in FIG. 27B. Similar to otherembodiments discussed herein, first, second, and third links 532, 534,and 536 can be unattached to each other and therefore free tolongitudinally move independent of each other. Other link combinationsare also possible. For example, along with link 532, links 534 and 536can also span between diametrically opposed cuffs.

When using multiple suture loops or other type of filament loops toclose a tissue opening, some or all of the loops can be coupled togetherif desired to form a filament or suture net that closes the opening inthe tissue. By coupling filament or suture loops together, the resultingfilament or suture net can provide a more complete closure of the tissueopening and can be used to assure the loops are positioned correctlyduring the closure procedure. FIGS. 28A-32B illustrate variousembodiments of net links that can be used with a tissue closure deviceto produce a filament or suture net.

In one type of suture net, the individual links can be rigidly securedto each other to form a net link. For example, FIG. 28A illustrates oneembodiment of a net link 550 that can be used with tissue closuredevices having four arms. Net link 550 is similar to link combination510 shown in FIG. 24A, except that in net link 550, links 512 and 514are rigidly secured to each other at their point of intersection to forma central hub 552. As a result, central hub 552 divides link 512 intotwo separate portions 512 a and 512 b and link 514 into two separateportions 514 a and 514 b. As such, net link 550 has four separate linkportions 554 a-554 d, consisting of link portions 512 a, 512 b, 514 a,and 514 b, each extending radially outward from central hub 552 to besecured to corresponding cuffs 166 a-166 d. Links 512 and 514 can besecured to each other at hub 552 by adhesive, welding, fastener, or thelike, or can be integrally formed together as a link assembly.

During use, each link portion 554 can remain attached to itscorresponding cuff 166 when cuffs 166 are retracted proximally throughthe tissue by the penetrators, e.g., in a similar manner to thatdiscussed above with respect to the method shown in FIGS. 11A-11G. As aresult, all of the formed suture loop portions corresponding to linkportions 554 can be pulled proximally outward through the tissue whilehub 552 remains distal of the tissue wall (e.g., within a blood vessel).This produces a suture net or web. When the suture ends corresponding tothe suture net are tied off to close tissue opening 250′, hub 552 canremain aligned with tissue opening 250′ as shown in FIG. 28B, therebyensuring that the suture loops of the suture web properly come togetheron the inside of the tissue, while also providing structural strengthdue to the securing of the individual links at hub 552.

In another type of suture net, the suture loops can be loosely coupledtogether instead of being rigidly secured to each other. For example,FIG. 29A illustrates an alternative embodiment of a net link 560 thatcan be used with tissue closure devices having four arms. Net link 560is similar to net link 550, except that individual links 512 and 514 arenot rigidly secured to each other at their point of intersection.Instead, a ring 562 can be used to form the central hub where theindividual links 512 and 514 intersect. Each link 512, 514 can extendthrough ring 562 so the correspondingly formed suture loops 512′ and514′ intersect one another where they pass through ring 562, as shown inFIG. 29B. Ring 562 can allow links 512 and 514 (‘and therefore, thecorrespondingly formed suture loops 512’ and 514′) to movelongitudinally with respect to each other while still intersecting athub 562. Ring 562 can be rigid or flexible. In one embodiment, ring 562is at least large enough for cuffs 166 to pass therethrough.

In an alternative embodiment, ring 562 can be rigidly attached to one ofthe links 512 or 514 while the other link passes through ring 562without being attached thereto. This can allow the link to which ring562 is unattached to longitudinally move with respect to the link towhich ring 562 is attached. Ring 562 can be comprised of a loop ofsuture or any other biocompatible material.

Net link 560 can be used to close a tissue opening in a similar manneras net link 550. That is, each link portion can remain attached to itscorresponding cuff 166 when the cuffs are retracted proximally backthrough the tissue by the penetrators. Alternatively, if ring 562 islarge enough for cuffs 166 to pass therethrough, the method shown inFIGS. 12A-12D can be used for either link 512 or 514. That is, one ormore of the cuffs 166 can become detached from the correspondingpenetrator and be pulled across the opening and proximally through thetissue by being pulled by the cuff coupled to the opposite end of theindividual link. To do so, the cuff can pass through ring 562 beforepassing proximally through the tissue. Regardless of the manner of use,suture loops 512′ and 514′ of the suture net formed from net link 560can be pulled proximally outward through the tissue and tied off whileloop 562 remains over the tissue opening 250′, as shown in FIG. 29B.

FIG. 30A illustrates another embodiment of a net link 570 in which thelinks pass through ring 562. However, instead of extending between cuffson diametrically opposed arms, the individual links in net link 570extend between cuffs on adjacent arms. For example, in the depictedembodiment, first and fourth cuffs 166 a and 166 d are linked by firstlink 572 and second and third cuffs 166 b and 166 c are linked by secondlink 574. Because links 572 and 574 extend through ring 562, however,links 572 and 574 extend inward towards each other as they pass betweenthe cuffs, as shown in FIG. 30A.

When cuffs 166 corresponding to links 572 and 574 have been pulledproximally through the tissue and corresponding suture loops 572′ and574′ are tightened about tissue opening 250′, the tightening force ofeach suture loop attempts to pull the suture loop away from the centerof the opening and toward the corresponding adjacent penetrator pathwayholes in the tissue.

However, while allowing each suture loop 572′ and 574′ some movementaway from the center of opening 250′, ring 562 prevents suture loops572′ and 574′ from moving completely away from the center of theopening, as depicted in FIG. 30B. Net link 570 may be especially usefulfor closing openings that are elongated, but may be used to close anytype of tissue opening. If desired, ring 562 can have some elasticity toallow further movement of suture loops 572′ and 574′ away from eachother with greater tightening force.

FIG. 31A illustrates an embodiment of a net link 580 that can be usedwith a tissue closure device having six arms. Similar to net link 570,net link 580 also includes a pair of individual links that attach tocuffs on adjacent arms and pass through a ring. However, because sixarms are present, net link 570 can also have another link passingbetween the two unused cuffs on the two additional arms.

For example, in the depicted embodiment, first and second links 582 and584 pass through ring 562 as they respectively extend between cuff pairs166 a/166 f and 166 c/166 d. A third link 586 is positioned betweenlinks 582 and 584 and extends across tissue opening 250 betweendiametrically opposed cuffs 166 b and 166 e. Link 586 extends throughring 562, although this is not required. That is, link 586 may or maynot pass through the ring. As such, it is clear that net links can beused by themselves or in conjunction with other individual links or linkcombinations that are not a part of the net link.

Similar to net link 570, when corresponding suture loops 582′ and 584′are tightened about tissue opening 250′, the tightening force of eachsuture loop 582′ and 584′ attempts to pull the suture loop away from thecenter of the opening and toward the corresponding adjacent penetratorpathway holes in the tissue, as shown in FIG. 31B. The additional sutureloop 586′ can provide additional closure across opening 250′.

In some situations, portions of the tissue surrounding opening 250 maybe hardened or otherwise impenetrable due to various causes, e.g., dueto scar tissue. In those cases, one or more of the penetrators may beunable to penetrate through the tissue. Suture nets can be adapted to beused in those situations.

For example, after positioning a tissue locator over the opening in thetissue and extending the arms in one of the manners discussed above, itmay become apparent during the penetration phase that one or more of thepenetrators cannot penetrate through the tissue. For example, if duringthe use of penetrator actuation handle 502 (FIG. 23A), one or more ofthe penetrator actuators 504 are unable to be completely advanceddistally, this may signify that the penetrators corresponding to theun-advanced penetrator actuators are unable to penetrate through thetissue.

If the rest of the penetrators were allowed to continue distally throughthe tissue and attach to their corresponding cuffs, the un-advancedpenetrators would not advance through the tissue and therefore would notattach to their corresponding cuffs. As a result, the links associatedwith the unattached cuffs would not become attached to the penetratorsand would therefore not become attached to the suture loops coupled withthe corresponding penetrators. Thus, the closure of the opening could bedetrimentally affected. In one scenario, a portion of a suture loopcould remain within a vessel, not tied off or attached to anything else.

To prevent this from happening, the tissue locator can be withdrawn fromthe body after it has been determined which penetrators cannot penetratethrough the tissue and before any of the penetrators have attached tothe cuffs. A suture net or web can then be formed and attached to thecuffs in the tissue locator corresponding to the penetrators that canpenetrate through the tissue. The cuffs corresponding to theun-penetrating penetrators can be left unattached or can be removed fromthe arms. The tissue locator can then be re-inserted into the body andthe suture net or web can be used to close the opening.

For example, let us assume that a tissue locator having six arms is usedto attempt to position three suture loops about tissue opening 250 usinglinks 590, 592, and 594 configured as shown in FIG. 32A. After thetissue locator has been positioned over the opening and the armsextended, however, it becomes apparent during the penetration phase thatthe sixth penetrator cannot penetrate through the tissue. Before theother penetrators have been extended far enough to attach to theircorresponding cuffs, the penetrators can be withdrawn back into thetissue locator, the arms rotated back to the retracted position and thetissue locator withdrawn through the opening and from the body.

The original three links can then be replaced by a net link 596 havingfive link portions 598 a-598 e extending radially outward from a hub 599to respectively attach to the first through fifth cuffs 166 a-166 ecorresponding to the penetrating first through fifth penetrators; thesixth cuff 166 f corresponding to the un-penetrating sixth penetratorcan be left unattached or can be removed from the corresponding sixtharm, as shown in FIG. 32B. As such, in the embodiment depicted in FIG.32B, only five of the six cuffs 166 are used to form net link 596.

The tissue locator can then be re-inserted through the opening 250 andnet link 596 can be deployed in one of the manners discussed above usingonly the penetrating first through fifth penetrators. The suture endsassociated with net link can then be used to secure and close theopening as shown in FIG. 32C.

It is appreciated that the suture nets discussed above can be adaptedfor use with tissue closure devices having any number of arms. It isalso appreciated that suture nets and suture loops can be mixed andmatched with each other in the same tissue closure device, as desired.

Although the discussion with respect to tissue locators has beendirected to the use of two, four, and six arms and associated cuffs andpenetrators, it is appreciated that the discussion can be applied theuse of any number of arms and associated cuffs and penetrators. Forexample, three, or five or more arms may be used. In some embodiments,six, eight, ten, or more arms may be used. In some embodiments an oddnumber of arms may be used, e.g., where one or more cuffs have aplurality of suture ends extending therefrom. As such, the presentinvention encompasses the use of more than two needles and associatedreceptacles, cuffs, sutures, and the like. Also as a result, a widevariety of stitching patterns can be provided by such multiple loopprobes.

Because the arms are radially spaced about the opening, multiple suturelinks can be formed as well as one or more suture nets using the cuffsin the arms. In general, for any even number n of arms, a number l oflinks equal to half the number of arms can be formed. For example fortissue locators having six, eight, and ten arms, three, four, and fivelinks can be formed, respectively. The links can be formed betweendiametrically opposed cuffs or between any of the cuffs, in the mannerdiscussed above. Similarly, any number of arms can be used in forming asuture net.

Although various embodiments of penetrators, penetrator receptacles,cuffs, means for releasably attaching the penetrator to the cuff,bights, knots, etc. have been discussed herein, it is appreciated thatother configurations of said components are also encompassed by thepresent invention.

The present disclosure may be embodied in other specific forms withoutdeparting from its spirit or essential characteristics. The describedembodiments are to be considered in all respects only as illustrativeand not restrictive. The scope of the disclosure is, therefore,indicated by the appended claims rather than by the foregoingdescription. All changes which come within the meaning and range ofequivalency of the claims are to be embraced within their scope.

What is claimed is:
 1. A method for closing an opening extending througha tissue wall, the method comprising: inserting a distal end of a tissuelocator distally through the opening, the tissue locator comprising afirst arm and a second arm each extending between a proximal end and adistal end, the first and second arms each being aligned along a shaftof the tissue locator in a retracted configuration, the tissue locatorbeing inserted far enough through the opening that the first and secondarms are positioned distal of the tissue wall, first and second ends ofa flexible filament respectively being removably coupled with the firstand second arms; pivoting the proximal end of each of the first andsecond arms of the tissue locator about the distal end of the respectivearm to move the proximal ends of the first and second arms from theretracted configuration to a deployed configuration in which theproximal ends of the first and second arms extend laterally away fromthe shaft; advancing a first penetrator and a second penetrator distallythrough the tissue wall such that the first and second penetratorsrespectively couple with the first and second ends of the flexiblefilament; and withdrawing the first and second penetrators proximallythrough the tissue wall, thereby causing the first and second ends ofthe filament to uncouple from the first and second arms, the first endof the flexible filament remaining coupled with the first penetratorsuch that the first end of the filament withdraws proximally through thetissue wall with the first penetrator.
 2. The method recited in claim 1,wherein the distal ends of the first and second arms remain alignedalong a shaft of the tissue locator in the deployed configuration. 3.The method recited in claim 1, wherein the distal ends of the first andsecond arms are integrally formed with the shaft of the tissue locator.4. The method recited in claim 1, wherein the distal ends of the armsare hingedly attached to the shaft of the tissue locator.
 5. The methodrecited in claim 1, wherein the distal ends of the arms flex outwardwhen the proximal ends of the arms move to the deployed configuration.6. The method recited in claim 1, wherein the second end of the flexiblefilament remains coupled with the second penetrator such that the secondend of the filament withdraws proximally through the tissue wall withthe second penetrator.
 7. The method recited in claim 1, wherein theproximal ends of the first and second arms extend in opposite lateraldirections when the arms are in the deployed configuration.
 8. Themethod recited in claim 1, wherein pivoting the proximal ends of thearms comprises moving an arm expander axially along the shaft so as tocause a laterally outward force to occur on the arms.
 9. The methodrecited in claim 8, wherein moving the arm expander axially comprisesmoving the arm expander proximally to cause the laterally outward forceto occur on the arms.
 10. The method recited in claim 8, wherein movingthe arm expander axially comprises moving the arm expander distally tocause the laterally outward force to occur on the arms.
 11. The methodrecited in claim 1, wherein the tissue locator further comprises a thirdarm and a fourth arm each extending between a proximal end and a distalend, first and second ends of a second flexible filament respectivelybeing removably coupled with the third and fourth arms, and wherein thethird and fourth arms are also each aligned along the shaft of thetissue locator in the retracted configuration and the third and fourtharms are positioned distal of the tissue wall when the tissue locator isinserted through the opening, and wherein the method further comprises:pivoting the proximal end of each of the third and fourth arms of thetissue locator about the distal end of the respective arm to move theproximal ends of the third and fourth arms from the retractedconfiguration to a deployed configuration in which the proximal ends ofthe third and fourth arms extend laterally away from the shaft;advancing a third penetrator and a fourth penetrator distally throughthe tissue wall such that the third and fourth penetrators respectivelycouple with the first and second ends of the second flexible filament;and withdrawing the third and fourth penetrators proximally through thetissue wall, thereby causing the first and second ends of the secondfilament to uncouple from the third and fourth arms, the first end ofthe second flexible filament remaining coupled with the third penetratorsuch that the first end of the second filament withdraws proximallythrough the tissue wall with the third penetrator.
 12. The methodrecited in claim 11, wherein the second end of the second flexiblefilament remains coupled with the fourth penetrator such that the secondend of the second filament withdraws proximally through the tissue wallwith the fourth penetrator.
 13. The method recited in claim 11, whereinthe proximal ends of the third and fourth arms extend in oppositelateral directions from each other and in lateral directions differentthan the lateral directions of the proximal ends of the first and secondarms when the third and fourth arms are in the deployed configuration.14. The method recited in claim 11, wherein moving an arm expanderaxially along the shaft also causes a laterally outward force to occuron the third and fourth arms to pivot the third and fourth armslaterally outward.
 15. A method for closing an opening extending througha tissue wall, the method comprising: inserting a distal end of a tissuelocator distally through the opening, the tissue locator comprising aplurality of arms, each being aligned along a shaft of the tissuelocator in a retracted configuration, the tissue locator being insertedfar enough through the opening that the plurality of arms are positioneddistal of the tissue wall, at least one flexible filament or web beingremovably coupled with the plurality of arms; moving the plurality ofarms from the retracted configuration to a deployed configuration inwhich the plurality of arms extend laterally away from the shaft; foreach arm, advancing a penetrator distally through the tissue wall tocouple with the at least one flexible filament or web associated withthe arm, the penetrators being movable independent of each other; andwithdrawing the penetrators proximally through the tissue wall, therebycausing the at least one flexible filament or web to uncouple from theplurality of arms and withdraw proximally through the tissue wall withthe penetrators.
 16. The method recited in claim 15, wherein eachpenetrator is advanced at different times from each other.
 17. Themethod recited in claim 15, wherein each penetrator has a separatepenetrator actuator associated therewith, and each penetrator isadvanced and withdrawn by manually manipulating the associatedpenetrator actuator.
 18. A method for closing an opening extendingthrough a tissue wall, the method comprising: inserting a distal end ofa tissue locator distally through the opening, the tissue locatorcomprising a plurality of arms, each being aligned along a shaft of thetissue locator in a retracted configuration, the tissue locator beinginserted far enough through the opening that the plurality of arms arepositioned distal of the tissue wall; advancing a plurality ofpenetrators distally to attempt to penetrate through the tissue wall,each penetrator being associated with a different one of the arms, oneor more penetrators not penetrating through the tissue wall; removablycoupling separate ends of a filament net with the plurality of arms, oneor more of the plurality of arms associated with the nonpenetratingpenetrators not being coupled with the filament net; moving theplurality of arms from the retracted configuration to a deployedconfiguration in which the plurality of arms extend laterally away fromthe shaft; for each arm associated with penetrating penetrators,advancing a penetrator distally to penetrate through the tissue wall,the penetrators penetrating through the wall to couple with the end ofthe filament net associated with the corresponding arm; and withdrawingthe penetrators proximally, thereby causing the ends of the filament netto uncouple from the plurality of arms and withdraw proximally throughthe tissue wall with the penetrators.